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THE   BEST  METHOD  OF  TEACHING 

OBSTETRICS  AND  AIDS   IN 

OBSTETRIC  TEACHING 


BY 


JAMES   CLIFTON    EDGAR,    M.D. 


ASSOCIATE    PROFESSOR    OF    OBSTETRICS    AND    GYNyECOLOGY    IN  THE   MEDICAL   DEPARTMENT   OF  THE   UNIVERSITY    OF   THE 

CITY   OF    NEW   YORK  ;    ATTENDING    PHYSICIAN    TO  THE   SOCIETY    OF   THE   LYING-IN    HOSPITAL,    TO    THE 

NEW    YORK   MATERNITY    AND   TO    THE    EMERGENCY    HOSPITAL;    LECTURER    AND    EXAMINER 

ON    OBSTETRICS    IN    THE    NEW    YORK   TRAINING    SCHOOL    FOR    NURSES 


WITH    NUMEROUS    ILLUSTRATIONS 


REPRINTED   FROM    THE   NEW    YORK  MEDICAL   JOURNAL 
OF  NOVEMBER   14,  21,  sS,   AND   DECEMBER  j,   i8g6. 


N  H  W     YORK 

D.    APPLETON     AND     COMPANY 

1896 


I^Q-  s:i^ 


Copyright,  1896, 
BY    D.   APPLETON    AND    COMPANY. 


THE  BEST   METHOD   OF   TEACHING    OBSTETKICS. 


It  is  a  little  more  than  seven  years  ago  that  our 
honored  fellow,  Dr.  Theophilus  Parvin,  at  the  thir- 
teenth annual  meeting  of  this  academy,  made,  as  the 
majority  of  us  will  recollect,  a  most  earnest  plea  for 
practical  obstetrics  in  the  courses  of  instruction  given  by 
our  medical  colleges.  It  was  then  clearly  shown  by  him 
that  while  the  science  of  obstetrics  was  admirably  taught 
in  many  of  our  American  medical  schools,  the  art  of 
midwifery  was  and  had  been  sadly  neglected;  that  the 
vast  majority  of  American  medical  students  graduated 
each  year  without  ever  having  witnessed,  still  less  having 
had  charge  of,  a  case  of  labor;  that  in  many  medical 
schools  not  even  the  practical  diagnosis  of  pregnancy 
by  palpation  and  auscultation  was  taught. 

The  truth  of  these  statements  has  never  been  ques- 
tioned. Up  to  that  time  it  had  been  customary  in  this 
country  for  most  medical  students  to  graduate  either 
without  any  practical  knowledge  of  midwifery,  or  with 
such  only  as  they  were  able  to  obtain  by  witnessing  an 
occasional  case  in  a  clinic,  or  possibly  by  treating  women 
in  coniinement  in  their  own  homes  without  the  super- 
vision or  aid  of  an  instructor. 

The  result  was  inevitable.  The  art  of  obstetrics 
was  learned  by  the  young  practitioner  often  at  the  ex- 
pense of  serious  if  not  fatal  injury  to  his  first  confinement 
cases.  During  the  past  decade  a  revolution  has  been  in 
progress  in  the  teaching  of  medicine  in  this  country. 
The  two-  and  three-year  courses  are  gradually  but  surely 
being  replaced  by  four  years  of  instruction;  college  terms 
of  five,  six,  or  seven  months  are  being  lengthened  to 
eight  and  even  nine. 

The  haphazard  theoretical  or  didactic  teaching  of  the 
old  two-year  course  has  already  been  largely  supplanted 
by  systematic  recitations  and  practical  and  thorough 
laboratory  instruction.  The  clinical  instruction  to  large 
audiences  of  former  years  is  generally  supplemented  by 
practical  clinical  work  performed  by  small  sections  of 
the  class.  In  many  medical  colleges  it  is  undoubtedly 
still  customary  to  cling  to  the  old  form  of  lecture  de- 
livered to  large  audiences.  It  is,  however,  gradually 
but  surely  being  replaced  by  systematic  graded  courses 
of  practical  and  clinical  instruction. 

Has  the  subject  of  obstetrics,  usually  classed  as  the 
last  of  the  seven  fundamental  divisions  of  medicine, 
kept  pace  with  the  remaining  six  in  this  reform?  To  a 
certain  extent,  yes.  As  to  the  question  whether  it  has 
advanced  with  the  same  rapidity  as  the  others,  we  are 
compelled  to  answer  in  the  negative. 

The  history  of  medical  progress  in  the  past  few 
years  certainly  points  to  some  reform  in  the  teaching 

*  Read  before  the  American  Academy  of  Medicine,  Atlanta,  May  4, 


of  the  art  of  midwifery,  shown  in  marked  improve- 
ments in  the  matter  of  instruction  in  colleges  al- 
ready possessing  lying-in  departments,  and  in  the  estab- 
lishment of  new  institutions  whose  main  purpose  is  the 
imparting  of  practical  instruction,  not  only  to  the  under- 
graduate student,  but  to  the  graduate  physician  as  well. 

Ten  years  ago  not  a  single  medical  school  in  iS'ew 
York  city,  for  instance,  required  its  students  even  to 
witness  cases  of  confinement  before  graduating.  At 
that  time  there  were  nine  institution  in  New  York 
either  wholly  devoted  to  lying-in  patients,  or  with  lying- 
in  departments  attached,  and  in  none  of  these  was  sys- 
tematic instruction  in  obstetrics  given.  To-day  six 
medical  schools  require  that  each  student  before  gradua- 
tion shall  have  attended  at  least  six  cases  of  confinement, 
and  there  are  some  thirteen  institutions  devoted  wholly 
or  in  part  to  obstetrics,  five  of  these  giving  systematic 
instruction  to  students  in  midwifery. 

In  spite  of  these  facts,  there  appears  to  be  no  doubt 
that  the  teaching  of  obstetrics  generally,  throughout 
the  country,  is  at  this  time  anything  but  what  it  should 
be,  and  that  "  clinical  instruction  is  largely  conspicuous 
by  its  absence." 

"  The  number  of  great  maternity  hospitals  in  this 
country  in  which  students  can  receive  practical  training 
can  be  numbered  on  the  fingers  of  one  hand.  As  a  coun- 
try we  are  far  behind  in  this  matter."  f 

The  best  method  to  teach  midwifery  can  not  be  de- 
scribed under  any  single  method,  but  must,  of  necessity, 
be  a  combined  method — a  system — a  combination  of 
recitations,  demonstrations,  manikin  practice,  attendance 
upon  clinics,  practical  bedside  or  hospital  work,  and 
theoretical  lectures,  the  teaching  of  the  science  and 
art  of  obstetrics.  The  classified  knowledge  of  the  laws 
which  govern  menstruation,  ovulation,  pregnancy,  labor, 
the  puerperium,  and  obstetric  surgery  on  the  one  hand, 
and  the  intelligent  appreciation  and  practical  application 
of  the  acquired  classified  knowledge  at  the  bedside  on 
the  other. 

Although  history  tells  us  obstetric  science  has  had 
a  tardy  development,  that  not  until  the  sixteenth  or  sev- 
enteenth century  was  it  fully  established,  still,  from  an 
educational  standpoint,  the  science  has  far  outstripped 
the  art  in  the  race.  May  the  time  soon  come — and  the 
indications  point  to  its  being  not  far  away — when  both 
shall  be  equally  well  taught. 

The  natural  and,  as  experience  teaches  us,  the  best 
sequence  for  the  student  to  follow  is  for  him  to  acquire 
a  working  knowledge  of  the  science  of  obstetrics  before  he 
applies  himself  to  the  art.  This  he  does  in  his  recitations, 

f  Mann.  President's  Address.  Iramaclions  of  the  American  Chjiim 
cological  SorAety,  No.  20,  1895. 


THE  BEST  METHOD   OF  TEACHINO   OBSTETBIGS. 


clinics,  and  demonstrations.  Further,  we  believe  it  advis- 
able to  defer  the  taking  up  of  the  general  subject  of 
obstetrics  until  the  pupil  has  had  at  least  one  year's 
instruction  in  the  medical  school,  especially  in  physiolo- 
gy and  anatomy.  Without  this  preliminary  study  the 
student  can  not  profitably  or  comfortably  digest  instruc- 
tion in  the  elements  of  the  physiology  and  pathology 


FlQ.  1.— Vertical  meyiul  section  of  tlie  bony  pelvis  cast  in  aliimiuum  and 
mounted  by  means  of  a  hand  screw  upon  a  blackboard  and  tripod.  The 
bodies  of  tbe  lumbar,  sacral,  and  coccygeal  vertebree  are  outlined  and  num- 
bered. The  hand  screw  permits  tbe  cast  being  set  at  any  angle.  An  outline 
of  tbe  b(  ny  pelvis  showing  the  axis  of  the  pelvic  inlet  and  those  of  the  bony 
and  partiu"ient  outlets  is  permanently  sketched  upon  the  blackboard  below. 
(From  a  photograph.) 

of  the  puerperium,  delivery,  and  pregnancy.  He  must 
be  familiar  with  the  characters  of  the  various  tissues 
of  the  hard  and  soft  parts  concerned,  to  which  constant 
reference  is  made  in  his  recitation  year,  in  terms  of  mi- 
croscopic and  Mstological  anatomy. 


Whatever  may  be  the  place  of  topograpliieal  anatomy 
in  courses  of  anatomy  i^er  se,  its  consideration  should 
come  early,  at  the  very  beginning,  in  a  course  of  ob- 
stetric teaching.  It  is  in  a  high  degree  necessary  that 
the  pupil  shall  have  mastered,  by  the  time  he  enters  upon 
his  obstetric  training,  not  only  the  size,  shape,  and  con- 
sistency of  the  normal  lower  abdominal  and  pelvic  or- 
gans, but  the  relations  in  space  which  such  organs  as  the 
labia,  clitoris,  meatus  urinarius,  and  hymen,  together  with 
their  glands,  blood-vessels  and  nerves;  the  uterus  and 
vagina,  kidneys,  ureters,  bladder,  and  urethra;  the 
sigmoid  flexure,  rectum,  and  anus;  abdominal  aorta, 
ovarian,  external  and  internal  iliac,  and  uterine  arteries; 
ovaries,  Falloppian  tubes,  and  ligaments  of  the  uterus; 
pelvic  muscles,  peritona3um,  glandular,  vascular,  and 
aerve  supply,  sustain  to  one  another.  If  in  addition  the 
itudent  has  mastered  the  elements  of  histology,  then, 
md  only  then,  can  he  be  considered  fully  equipped 
to  receive  elementary  instruction  from  the  department 
of  obstetrics,  and  the  head  of  this  department  is  then 
free,  as  he  should  be,  to  direct  his  whole  energies  to  the 
.vork  which  he  has  been  appointed  to  undertake.  After 
this,  the  pupil's  work  in  obstetrics  should  be  so  sys- 
tematized as  to  blend  progressively  with  the  work  of  his 
remaining  three  years  in  the  medical  school,  and  render 
him  at  the  end  of  that  time  not  only  capable  of  answer- 
ing the  few  simple  questions  found  to-day  upon  the 
final  or  State  examination  paper,  but  fully  competent 
as  well  to  care  intelligently  for  women  in  normal  labor, 
and  at  least  to  recognize,  if  not  meet,  the  ordinary  com- 
plications of  the  lying-in  state,  labor,  and  pregnancy. 

E.xperience  has  taught  us  that  this  end  is  most  surely 
and  thoroughly  attained  by  pursuing  some  such  plan  as 
the  following,  in  the  sequence  named: 

I.  Systematic  biweekly  or  triweekly  recitations  dur- 
ing the  second  college  year. 

II.  (1)  Demonstrations  and  manikin  work;  (2)  at- 
tendance upon  obstetric  clinics;  and  (3)  laboratory  work 
during  the  third  collegiate  year. 

III.  A  resident  service  in  a  maternity  hospital,  which 
shall  include  (1)  the  examination  of  pregnancy  under 
competent  instructors;  the  actual  confinement  of  pa- 
tients by  tlie  student  himself,  under  rigid  supervision 
in  both;  (2)  "ward"  or  indoor  service,  and  (3)  "out- 
door "  or  polyclinic  service;  (4)  the  attendance  upon  the 
obstetric  clinics  of  the  hospital;  (5)  theoretical  lectures 
(illustrative  in  character);  and  (6)  recitations  subse- 
quently upon  the  previous  practical  work  performed  by 
the  student. 

IV.  Theoretical  lectures  (illustrative  in  character) 
upon  advanced  obstetrics. 

I.  Systematic  Biweekly  oe  Teiweekly  Eecitations 

DUEING  THE  SECOND  COLLEGE  YeAE. 

Attention  has  been  called  to  the  unfortunate  custom 
still  prevalent  in  many  medical  colleges  throughout  this 
country  to  teach  obstetrics  to  large  audiences  by  means 


THE  BEST  METHOD   OF  TEAOEISO   0BSTETRI08. 


of  the  didactic  or  theoretical  lecture.    Within  a  few  years 
the  attempt  has  been  made  b}'  certain  institutions  to 


a.  9.— Pelvis  and  blackboard  of  Fig.  1  used  to  demonstrate  forceps  applied  to 
fcetal  head  at  the  pelvic  inlet  and  dangers  that  result  from  the  faulty  posi- 
tion of  the  handles  and  traction  in  this  wrong  direction.    {From  a  photo- 


supplant  this  lecture  course  wholly  or  in  part  by  thi.' 
recitation.  Since  the  introduction  of  this  latter  method 
of  teaching  the  shortcomings  and  faults  of  the  old 
didactic  lecture,  still  generally  in  use,  have  become  mori' 
than  ever  apparent.  Moreover,  the  contrast  of  the  two 
systems  has  resulted  in  benefit  in  quite  another  way, 
since  it  has  markedly  changed  the  character  and  font' 
of  the  theoretical  lectures  which  still  exist  as  supple- 
ments to  the  recitational  and  practical  work,  raising 
them  to  a  higher  plane,  giving  them  a  more  practical  anil 
illustrative  form,  and  thus  making  them  in  every  wa} 
more  helpful  to  the  student. 

Although  the  advantages  of  the  recitation  systeu! 
are  more  perceptible  each  year  in  the  better  qualiiied 
graduating  classes,  still,  we  believe  the  recitation,  so  fai 
as  obstetrics  is  concerned,  can  be  made  of  still  greatei 
value  and  interest  to  the  student,  even  though  the  in 
structors  be  comparatively  young  men. 

It  is  not  sufficient  that  the  section  of  twenty  or 
thirty  pupils  be  required  to  learn  and  recite  in  a  per- 
functory manner  the  principles  and  laws  of  obstetric  sci- 
ence as  set  forth  in  some  good  text-book  in  biweekly  or 
triweekly  recitations,  but  these  principles  and  laws  must 
be  brought  home  and  rendered  real  and  interesting  to 
him  by  abundant  illustration. 

Perhaps  in  no  other  branch  of  medicine  is  this  ob- 


ject so  readily  attained  as  in  obstetrics,  since  the  under- 
lying principles  of  the  subject  for  the  most  part  rest  upon 
the  well-known  laws  of  anatomy,  physiology,  and  phys- 
ics, all  of  which  permit  a  wide  range  of  illustration. 

No  department  of  obstetrics  is  to-day  complete  with- 
out such  means  of  illustration,  and  it  should  be  the  in- 
structor's duty  to  make  such  intelligent  use  of  them  as 
to  supplement  the  labors  of  the  head  of  the  department, 
relieve  him  of  much  of  the  theoretical  work,  and,  at  the 
same  time,  better  prepare  the  student  for  an  intelligent 
appreciation  of  his  subsequent  demonstration  work,  at- 
tendance upon  obstetric  clinics,  and  finally  for  his  resi- 
dence in  the  maternity  hospital. 

The  instructor  will  do  well  if,  at  the  beginning  of 
the  session,  he  lays  out  a  schedule  for  his  "entire  course, 
gauging  his  hours  of  recitation  so  as  to  cover  the  entire 
field  of  the  subject  in  the  teaching  year. 

There  should  be  plenty  of  blackboard  space  at  his 
command — pelves  entire,  sagittal  and  transverse  sections 
of  the  same,  diagrams  and  charts,  carefully  selected  mod- 
els, wet  and  dry  preparations,  and  the  more  common  ob- 
stetric instruments. 

,With  a  little  ingenuity  and  forethought  each  indi- 
vidual member  of  a  section  of  say  twenty  students  may  be 
tested  regarding  his  appreciation  of  the  subject  in  hand 
during  the  recitation  hour. 

This  is  readily  accomplished  by  assigning  a  portion 


Fig.  8.— Pelvis  and  blackboard  of  Fig.  1,  showing  breech  presentation  with  left 
buttock  caught  at  the  pelvic  inlet  and  the  dangers  of  faulty  traction  on  the 
prolapsed  leg  in  a  horizontal  plane.    (From  a  photograph.) 

of  the  section  to  the  blackboard,  to  execute  there  a  dia- 
gram, enumerate  a  series  of  principles,  or  write  defini- 
tions, which  are  subsequently  criticised  by  the  instructor. 
Another  squad  is  assigned  to  a  number  of  wet  and  dry 
specimens  conveniently  placed  on  trays,  which  the  stu- 
dent, after  a  time  given  to  look  them  over,  is  called  upon 
to  demonstrate. 


THE  BEST  METHOD   OF  TEACHTN'O   OBSTETRICS. 


Among  the  wet  specimens  of  especial  use  at  tliis 
time  are  placenta  with  membranes  and  cord  attached 
and  preserved  in  alcohol  or  formalin;  ova  of  the  first 
few  months  to  demonstrate  the  transition  from  chorion 
to  placenta,  the  amnion,  the  umbilical  vesicle,  and  so  on; 
a  uterus  showing  the  decidua  of  menstruation,  another 
the  decidua  of  pregnancy;  also  a  collection  of  preserved 
embi-yos  and  foetuses,  all  of  which  the  student  shall  be 
required  to  inspect  or  measure,  and  describe  not  only  the 
gross  appearances  and  characteristics,  but  also  the  chro- 
nology of  each.  Any  or  all  of  these  specimens  the  pa- 
thologist of  a  maternity  or  large  general  hospital  may 
readily  secure. 

The  dry  preparations  may  include  mounted  placentiE, 
injected  through  the  vessels  of  the  cords  with  different 
colored  material  or  corrosive  preparations  of  the  same. 
These  may  comprise  the  normal  conditions  of  the  vessels 
and  departures  therefrom. 


Fig.  4.— Pelvis  and  blackboard  of  Fig.  1  used  to  demonstrate  sling  applied  to 
the  breech  and  faulty  direction  of  traction  thereon.  Position  of  double  sling 
for  breech  extraction  also  illustrated.    (From  a  photograph.) 

Still  another  squad  is  in  the  same  way  assigned  to 
carefully  selected  models,  and  the  remainder  of  the  class 
is  then  questioned  upon  the  subject  of  the  day,  enough 
of  the  latter  part  of  the  hour  being  reserved  for  demon- 
strations and  criticisms  of  those  assigned  to  the  black- 
board, specimens,  and  models.  Such  a  plan  is  by  no 
means  difficult  to  carry  out,  as  experience  will  prove. 

Regarding  the  models,  there  is  practically  no  limit 
to  their  number,  as  we  show  in  another  place  (demon- 
strations and  manikin  work),  but  perhaps  the  most  use- 
ful of  them  all  at  this  time  will  be  found  a  sagittal  sec- 
tion of  the  pelvis,  cast  in  aluminum,  and  so  mounted 
upon  a  portable  blackboard  as  to  allow  of  being  fixed  in 
the  proper  planes  of  both  dorsal  and  upright  positions. 

Nothing  has  been  of  greater  aid  to  us  than  this 


contrivance,  since,  with  chalk,  pelvic  planes,  angles, 
curves  of  bony  pelvis,  and  parturient  canal  may  be  clear- 
ly demonstrated. 

We  can  not  too  strongly  urge  the  importance  and 
the  benefit  to  the  student  of  actually  handling  the  wet 
and  dry  preparations,  pelves  in  whole  or  in  part,  models, 
and  instruments  used  in  the  recitation. 

To  illustrate  the  foregoing,  take  the  subject  of  pel- 
vic deformity,  for  example.  Five  students  are  assigned 
to  manikins  with  the  sacral  promontories  set  to  give  true 
conjugates  from  three  inches  and  three  quarters  to  two 
inches  and  a  half.  A  pelvimeter  is  at  hand,  and  the  stu- 
dents are  asked  to  state,  after  examining  the  diagonal 
and  true  conjugates,  the  difference  between  these,  ihe 
factors  influencing  this  difl'erence,  the  effect  on  labor 
of  the  contracted  pelvis,  and  the  necessity  for  interfer- 
ence. 

Among  another  squad  of  five  pupils  are  distributed 
five  copper-plated  models  of  moderate  pelvic  deformity, 
and  by  means  of  a  pelvimeter  the  students  are  requested 
to  find  the  more  important  diameters,  and  finally  to  state 
the  probable  cause  of  deformity,  and  the  effect  upon 
labor  of  the  same. 

Still  another  squad  of  five  pupils  is  assigned  black- 
board space,  one  to  enumerate  the  principal  pelvic  diame- 
ters and  their  usual  lengths,  another  to  demonstrate  the 
three  conjugates  of  the  pelvic  brim,  another  the  more 
common  kinds  of  pelvic  deformity,  another  the  causes, 
and  still  another  the  methods  of  delivery. 

The  remainder  of  the  section  can  now  be  quizzed 
upon  some  special  branch  of  the  subject — for  example,  the 
relation  between  pelvic  contraction  and  malpresenta- 
tion,  position,  and  attitude,  as  illustrated  by  means  of 
models  in  sagittal  and  transverse  sections;  and,  lastly,  the 
work  of  each  individual  student  is  inspected,  and  if 
necessary  criticised,  the  whole  section  being  appealed  to 
for  opinions  on  difficult  points. 

II.  (1)  Demonstrations  and  Manikin  Wokk;  (3) 
Attendance  upon  Obsteteic  Clinics;  (3)  and 
Laboeatokt  Work  during  the  Third  Collegiate 
Year. 

Not  even  at  this  time  in  the  student's  course  is  it 
practical  or  advisable  to  attempt  to  handle  classes  that 
exceed  thirty. 

It  is  desirable  that  the  position  of  instructor  in  ob- 
stetrics take  on  more  the  nature  of  a  demonstration  of 
obstetrics;  that  his  department  consist  of  a  combined 
museum,  manikin,  and  recitation  room,  furnished  with 
a  generous  supply  of  manikins,  models,  embryological, 
anatomical,  and  pathological  wet  and  dry  specimens, 
charts,  diagrams — in  short,  all  the  recognized  aids  to 
obstetric  teaching. 

In  such  an  obstetrical  laboratory  the  recitations  and 
demonstrations  should  be  conducted  to  small  sections  of 
the  class  as  above  described. 


THE  BEST  METHOD   OF  TEACHING   OBSTETRICS. 


1.  Demonstrations  and  Manilcin  Worh. 

So  far  as  the  demonstrations  and  manikin  work 
go,  biweekly  or  triweekly  meetings,  for  a  period  of 
six  to  eight  weeks,  will  pretty  thoroughly  cover  the 
ground. 

It  is  well  for  the  instructor  to  aim  in  this  section 
work  not  only  at  a  systematic  course  in  manikin  work, 
but  also  at  the  same  time  a  review  of  the  theoretical 
work  gone  over  in  the  second  year,  giving  it,  so  far  as 
possible,  a  practical  application.  This,  with  a  little  at- 
tention, can  be  readily  accomplished. 


The  models  may  be  of  plaster,  or  papier-mache  repro- 
ductions of  plaster  and  clay,  copper-plated  models,  or 
composition,  or  of  a  miscellaneous  character.  With 
them  the  parturient  canal  with  its  curves;  the  mechanism 
of  cervical  dilatation  in  primiparae  and  multiparas;  the 
size  and  shape  of  the  uterus  at  the  several  months  of  ges- 
tation; the  degrees  of  uterine,  vaginal,  and  perineal  rup- 
tures, and  methods  of  the  repair  of  the  latter;  involution 
of  the  puerperal  uterus,  as  shown  in  a  series  of  papier- 
mache  reproductions  of  frozen  sections;  the  various  forms 
of  pelvic  deformity;  the  action  and  use  of  various  cervi- 


FiG.  5, — Pelvis  of  Fifr.  1.    Manual  method  of  meatsi 

Here  again,  with  a  little  ingenuity,  most,  if  not  all, 
of  the  section  or  squad  may  he  assigned  some  task  to 
perform  during  a  given  hour,  so  that  the  student  shall 
take  as  active  a  part  as  possible,  leaving  little  of  his 
time  without  some  occupation. 

Such  demonstrations  and  manikin  work  will  call  for 
more  apparatus,  models,  and  specimens  than  was  re- 
quired in  the  recitations  of  the  preceding  year.  An 
abundance  of  blackboard  space  is  required  as  before; 
pelves  entire,  and  in  sagittal  and  transverse  sections, 
must  be  constantly  at  hand;  three  or  four  good  manikins, 
with  a  supply  of  puppets,  foetal  cadavers  (preserved  in 
formalin  or  alcohol),  embryos,  foetuses,  placenta3,  with 
their  membranes  in  different  stages  of  development,  and 
carefully  selected  models  for  use  alone  and  in  con- 
junction with  the  manikins. 


Ing  the  diagonal  conjugate.    tFrom  a  photograph.) 

eal  dilators;  the  intra-uterine  tamponade;  the  puerperal 
ciirette;  the  ligature  in  cervical  hcemorrhage;  manual 
dilatation  of  the  os,  and  many  other  obstetric  condi- 
tions. (See  Aids  in  Obstetric  Teaching,  to  be  published 
in  a  subsequent  number.)  We  must  insist,  however,  upon 
the  recognition  of  the  proper  place  of  these  models  in  ob- 
stetric teaching,  and  sound  a  caution  regarding  their  use. 
They  should  be  viewed  as  auxiliaries,  as  adjuncts,  and  as 
a  better  preparation  for  subsequent  practical  instruction; 
and  care  must  be  used  that  no  false  or  exaggerated  im- 
pression is  conveyed  to  the  student  in  their  use.  In  an- 
other paper  we  shall  describe  in  detail  the  manner  of 
their  production.  As  in  the  recitation  system,  the  same 
general  plan  of  assigning  work  may  be  employed,  the 
student,  however,  being  required  to  take  a  more  active 
part. 


TEE  BEST  METHOD   OF  TEACHING   OBSTETBICS. 


Thus,  by  a  general  illustration  and  a  demonstration 
form  of  instruction,  much  that  heretofore  has  been  more 
or  less  problematical  may  be  cleared  up,  and  new  interest 
may  be  given  to  many  obstetric  subjects  which,  by  rea- 
son of  their  obsoureness  and  "dryness,"  proved  stum- 
bling blocks  to  the  student,  and  later  to  the  practising 
physician. 

This  is  the  time  and  opportunity  given  the  student 
to  acquire  that  manual  training  in  obstetric  procedures 
which  may  never  recur  until  he  is  in  active  practice,  and 
he  should  be  made  to  appreciate  his  advantages. 

It  is  at  this  time  that  he  acquires  the  kind  of  train- 
ing which  gives  to  the  intending  physician  the  practice 
to  make  him  intelligent  and  expert  in  the  use  of  his 
knowledge;  the  kind  of  training  which  saves  the  newly 


orrhage.  Eight  or  ten  students  are  assigned  to  manikins, 
in  which  are  placed  leather  models  of  the  puerperal 
uterus.  Gauze,  volsella,  dressing,  and  needle  forceps,  nee- 
dles and  ligatures,  and  specula,  all  of  which  are  part 
of  the  equipment  of  the  department,  are  at  hand. 

Each  student,  with  the  assistance  of  a  second,  and 
under  the  supervision  of  the  instructor,  is  required  to 
pack  the  uterus  with  gauze  (Fig.  7)  and  also  place  a  liga- 
ture in  the  apex  of  the  laceration  in  the  neck  of  the 
model  (Fig.  8).  The  models  are  then  removed  from 
the  manildn,  and  the  manner  of  gauze  packing  and  the 
position  of  the  ligature  demonstrated  and  criticised 
by  the  instructor.  Copper-plated  plaster  casts  of  the 
several  degrees  of  vaginal  and  perineal  lacerations  are 
distributed  to  other  pupils  for  inspection  and  subsequent 


Flo.  6. — PelviB  of  Fig.  1.    Instrumental  method  of  measuring  tlie  obstetrical  conjugate  directly  by 


of  Faraba?uf' 8  pelvimeter. 


appointed  hospital  interne  the  mortification,  in  the  pres- 
ence of  his  seniors,  of  applying  the  forceps  upside  down; 
the  kind  of  training  which  causes  the  interne  or  newly 
appointed  instructor  ever  to  remember  that  there  is  such 
a  thing  as  a  curve  to  the  parturient  canal,  and  that  trac- 
tion with  the  forceps  applied  to  the  brim  or  on  a  leg  in 
high  arrest  of  the  breech,  in  a  horizontal  plane,  quite 
possibly  result  in  disaster  to  mother  and  child!  For  close 
observation  will  show  that  improper  and  faulty  traction 
with  the  forceps  has  cost  the  lives  of  more  mothers  and 
children  than  almost  any  other  obstetric  operation,  in 
proportion  toils  frequency.  To  impress  this  fact  upon  the 
pupil's  mind,  he  must  be  made  to  see  in  what  the  danger 
lies.  By  means  of  such  training  the  physician's  first  cases 
of  confinement  will  be  saved  much  that  otherwise  would 
be  experimental  and  crude  in  the  manner  of  treatment. 
Take,  for  example,  the  subject  of  post-partum  haem- 


demonstration.  Other  students  are  assigned  blackboard 
space  to  enumerate  origin  of  hfemorrhage  after  delivery, 
mechanism  and  causes,  and  principles  of  treatment. 

Such  a  course  can  not  be  considered  complete  with- 
out an  occasional  demonstration  of  the  diagnosis  of 
pregnancy  upon  the  living  subject.  Cases  of  pregnancy 
may  for  this  purpose  be  sent  in  from  the  dispensary  of 
the  institution  or  from  a  maternity  hospital. 

These  demonstrations  can  be  made  a  valuable  pre- 
liminary to  the  resident  hospital  course  to  follow  later. 
Information  obtained  by  inspection,  palpation,  and  aus- 
cultation can  be  interestingly  dwelt  upon  by  the  in- 
structor, and  appreciated  by  the  student. 

2.  Attendance  upon  Oistetric  Clinics. 

An  occasional  attendance  at  an  obstetric  clinic  during 
this  third  year  will  be  of  the  greatest  assistance  in  fixing 


THE  BEST  METHOD   OF  TEAOHINO   OBSTETRICS. 


Fig.  7.— Leather  model  of  puerperal  uterus  placed  in  manikin,  and  used  to  demonstrate  packing  of  the  puerperal  uterus  with  gauze  to  control  postpartum  hsemor- 
rhage  proper,  or  to  secure  drainage  in  atonic  or  septic  conditions  of  the  uterus. 


Fig.  S. — Leather  model  of  puerperal  uterun  placed  in  manikin,  and  used  to  demonstrate  treatment  of  powt-partum  hB3morrhage  due  to  a  deeply  lacerated  cervix. 


10 


TEE  BEST  METHOD   OF  TEACHING   OBSTETRICS. 


the  theoretical  work  of  the  second  year,  and  the  demon- 
strations and  manikin  work  the  student  takes  part  in  at 
this  time. 

If  possible,  his  time  should  be  so  laid  out  as  to  permit 
the  student  to  attend  over  a  stated  period  the  obstetric 
clinics  of  the  hospital,  or  until  he  has  watched  the  de- 
livery of  several  cases  of  confinement.  If  it  can  be  ar- 
ranged for  him  to  take  at  this  time  his  practice  in  the 
out-patient  department  of  the  hospital,  in  the  examina- 
tion and  diagnosis  of  pregnancy,  so  much  the  better, 
for  the  student  can  then  learn  the  preliminary  princi- 
ples of  cleanliness,  thus  anticipating  his  resident  service 
in  the  maternity. 

3.  Laboratory  Worh. 

Provision  should  be  made  for  those  students  who 
desire  special  opportunities  to  study  histology,  pathology, 
bacteriology,  and  embryology,  that  would  not  be  ob- 
tained in  the  regular  courses  of  the  colleges  they  attend. 
Little  time  will  be  left  for  such  work  after  the  regular 
laboratory  courses  in  histology,  pathology,  and  bacteri- 
ology, consequently  advanced  research  on  the  part  of 
the  student  is  best  undertaken  during  the  vacation  in- 
tervals or  after  graduation. 

III.  A  Eesident  Seetice  in  a  Maternity  Hos- 
pital, WHICH  SHALL  INCLUDE  (1)  THE  EXAMINA- 
TION OP  Peegnanct  under  Competent  Insteuct- 
OEs;  THE  Actual  Deliveet  oe  Patients  by  the 
Student  Himself,  dndee  Eigid  Supeevision,  in 
BOTH.  (3)  "  Ward  "  or  Indooe  Seevice.  (3) 
"  Outdoor  oe  Polyclinic  Seevice.  (4)  The 
Attendance  upon  the  Obsteteic  Clinics  of 
THE  Hospital.  Also  (5)  Theoeetical  Lectures 
(illusteative  in  character),  and  (6)  Eecita- 
TiONS  Subsequently  upon  the  Previous  Prac- 
tical Work  performed  by  the  Student. 

Resident  Maternity  Service. 

Without  entering  into  the  controversy  regarding  the 
actual  amount  of  participation  on  the  part  of  the  student 
in  the  practical  work  of  the  hospital  or  of  the  polyclinic 
or  "  outdoor "  service,  we  believe  that  such  obstetric 
courses  should  to-day  demand  not  only  that  the  student 
shall  witness  the  delivery  of  the  patients,  but  also  that 
he  shall  personally  actually  confine  the  patients,  always 
in  the  presence  of  an  expert  and  critical  instructor. 
Moreover,  the  subsequent  care  of  the  puerperal  woman 
and  newborn  child  should  rest  with  the  student,  always 
again  under  a  complete  system  of  cheeks  against  accident 
and  under  the  most  rigid  supervision.  That  this  is  not 
only  practical  but  possible  can  be  abundantly  shown  by 
records  of  thousands  of  cases  of  confinement  thus  man- 
aged without  accident. 

It  has  been  charged  against  this  practical  system 
of  teaching,  as  applied  to  the  medical  student,  that  it 
carries  with  it  a  high  mortality  rate,  and  that  the  pa- 


tients treated  under  such  a  system  are  subject  to  unneces- 
sary exposure. 

The  first  objection  is  abundantly  answered  by  the 
records  of  many  such  practical  systems  established  years 
ago  in  Germany,  and  by  those  of  several  established 
within  the  past  decade  in  this  country. 

The  latter  objection  can  only  hold  good  by  reason  of 
a  lapse  in  the  rigid,  critical,  and  constant  supervision 
on  the  part  of  the  instructors,  which  must  at  all  times 
pervade  such  practical  systems  of  instruction. 

The  student  will  best  appreciate  and  profit  by  this 
course  if  it  is  taken  during  his  third  year,  or,  better,  in 
vacation  time,  between  his  third  and  fourth  years,  when 
he  has  full  leisure  to  give  to  it.  He  should  be  brought 
to  look  upon  this  practical  course  as  the  most  valuable 
and  important  of  his  whole  obstetrical  teaching,  for  all 
that  he  has  previously  learned  is  to  be  tested  and  fixed 
in  his  mind;  theoretical  deductions  are  to  give  place  to 
practical  application;  he  will  now  not  only  observe  his 
classified  knowledge  applied  at  the  bedside,  but  use  and 
apply  it  himself. 

There  is  no  doubt  that  students,  as  a  rule,  fully  ap- 
preciate the  advantages  of  such  clinical  work,  although 
it  demands  extra  time  and  much  work.  It  is  no  un- 
common occurrence,  in  one  institution  at  least  devoted 
to  education  in  practical  obstetrics,  for  the  student  to 
ask  the  privilege  to  remain  over  his  regular  period  of 
service,  or  even  to  return  after  a  lapse  of  several  months 
and,  repeat  his  practical  obstetric  course,  although  he  has 
already  more  than  fulfilled  the  requirements  for  gradua- 
tion. 

1.  The  Examination   of  Pregnancy.   2.    The   "Ward" 

Service. 

It  is  advisable  that  the  first  of  the  student's  observa- 
tions should  be  in  the  examination  of  pregnancy.  The 
first  few  days  of  his  service  should  be  rather  passive  ones. 
He  should  be  called  to  witness  all  the  deliveries  and 
operations  in  the  wards  or  operating  room;  he  should 
attend  such  clinical  lectures  as  shall  be  given;  accom- 
pany the  attending  or  resident  physician  in  his  diurnal 
rounds,  and  in  addition  should  spend  several  hours  each 
day  in  the  out-patient  examining  room  or  waiting  ward, 
where,  under  a  competent  instructor,  he  should  be  re- 
quired to  take  an  active  part  in  the  examination  and 
diagnosis  of  pregnancy,  including  pelvimetry,  and 
should,  under  the  supervision  of  the  instructor,  be  re- 
quired to  fill  in  properly  and  sign  his  name  to  the  liis- 
tories  of  pregnancy.  It  will  be  well  if  the  record  charts 
used  at  tliis  time — and  later  for  confinement  cases  and 
the  newborn  child — be  fuller  and  more  detailed  in  their 
requirements  than  perhaps  the  medical  records  of  a 
hospital  would  demand.  This  is  intended  to  bring  out 
the  student's  faculties  of  observation,  and  a  wider  con- 
sideration of  the  subject  than  is  generally  considered 
necessary.  Examinations  thus  carried  out  under  the 
eye  of  the  instructor,  with  attention  to  minute  details, 


TBE  BEST  METHOD   OP  TEAOHINQ   OBSTETBIOS. 


11 


as  well  as  general  observations  in  the  examination  and 
care  of  even  a  few  cases  of  pregnancy,  labor,  and  new- 
born children,  will  prove  of  far  greater  advantage  to  the 
student  than  a  much  greater  number  cared  for  by  him 
without  direct  instruction  and  supervision. 

No  better  time  than  this  can  be  selected  to  incul- 
cate in  the  student  the  principles  of  obstetrical  clean- 
liness, mechanical    and  chemical. 

Eules  and  exphcit  directions  for  personal  cleanli- 
ness and  disinfection  may  be  printed  to  advantage  in 
;  bold  type  and  hung  in  the  examining  room,  as  is  the 
custom  in  some  foreign  maternities,  notably  of  Prague. 
Moreover,  by  this  plan  the  same  rigid  cleansing  and  dis- 
infecting of  the  hand  and  forearm  is  applied  to  the  ex- 
amination of  pregnancy  as  to  that  of  labor,  and  to  carry 
it  out  properly  an  abundant  supply  of  fresh  water,  soap, 
brushes,  and  mercuric  chloride  are  called  for. 

With  an  abundance  of  material,  such  examinations 
of  the  dispensary  and  waiting  women  of  the  hospital 
may,  after  the  student  has  examined  several  cases  under 
proper  supervision,  readily  be  made  to  resemble  the 
"  touch  course  "  of  the  foreign  maternities. 

With  two  students  assigned  to  a  case  they  may  be 
given  time,  after  cleansing  of  their  hands  under  super- 
vision and  according  to  the  rules  of  the  institution,  to 
examine  the  women  both  externally  and  internally. 
The  instructor  in  charge  then  examines  the  cases  and 
questions  the  students  regarding  the  general  condition 
of  the  patient,  the  time  of  gestation,  posture  and  presen- 
tation of  the  foetus,  condition  of  the  mammary  glands, 
anterior  abdominal  "walls,  external  genitals,  pelvic  con- 
tents, size  of  the  bony  pelvis,  and  departures  from  the 
normal  in  hard  or  soft  parts. 

He  may  now,  with  great  precaution,  be  permitted  to 
examine  several  cases  in  labor  in  the  wards  or  delivery 
room;  then  under  rigid  and  expert  supervision  he  may 
be  allowed  to  care  for  the  entire  confinement.  The  in- 
structor must  stand  ready  at  this  time  to  correct  errors  in 
cleanliness,  and  criticise  unskillfulness  in  management. 
Under  the  supervision  of  the  instructor,  as  in  the 
examination  of  pregnancy,  the  student  should  be  di- 
rected in  the  filling  out  of  a  complete  history  of  labor 
and  child,  going  into  the  minutest  details  in  order  to 
train  his  faculties  of  observation,  and  to  this  his  name 
should  be  signed,  so  that  he  may  understand  that  he 
personally  is  held  to  account  for  the  future  welfare  of  the 
case. 

Should  the  student  remain  on  "  ward "  duty, 
the  future  care  of  the  case  is  assigned  to  him,  still  under 
supervision  of  the  ward  instructor,  and  the  daily  ob- 
servations upon  mother  and  child  are  taken  by  him 
and  criticised  at  the  diurnal  rounds  of  the  attending 
or  resident  physician. 

.3.  "  Outdoor  "  or  Polyclinic  Service. 
The  systematic  training  the  student  has  received  in  the 
wards  renders  it  possible  for  him  to  put  this  same  train- 


ing in  practice  in  the  care  of  women  in  their  own  homes. 
Thus,  a  large  class  of  the  poor  of  great  cities,  who  either 
can  not  or  will  not  enter  a  maternity  hospital,  may  be 
reached.  It  is  no  doubt  true,  so  far  as  this  country  is 
concerned,  that  while  a  small  proportion  of  the  poor 
dependent  upon  charity  for  proper  aid  in  confinement 
is  cared  for  in  maternity  hospitals,  by  far  the  greater 
number  remain  at  home  and  must  be  attended  there. 
Tliis  outdoor,  polyclinic,  or  tenement-house  service  on 
the  part  of  the  student  can  only  be  rendered  practical 
by  an  elaborate  and  carefully  supervised  system;  by  the 
most  thorough  checks  against  accident;  by  an  abundant 
supply  of  clinical  instructors;  and  by  establishing 
throughout  the  district  to  be  covered  by  the  service  a 
number  of  substations  to  the  main  hospital  building, 
so  situated  that  one  at  least  shall  be  easily  accessible  to 
each  patient  on  the  waiting  list,  and  all  in  touch  with 
the  main  hospital  by  means  of  telephonic  connection. 

Here,  again,  it  can  be  abundantly  proved  that  such 
a  system  is  not  only  feasible,  but  capable  of  being  car- 
ried on  successfully.  Eegarding  the  greater  advantage 
to  the  student  of  the  outdoor  maternity  system,  as  com- 
pared with  the  indoor  service,  there  can  be  no  question. 
In  the  former,  the  pupil,  being  thrown  more  upon  his 
own  resources  and  responsibility,  becomes  no  longer  a 
looker-on,  an  assistant,  but,  being  practically  in  charge 
of  the  case  of  confinement,  he  profits  by  his  experience 
accordingly.  The  limits  of  the  present  paper  forbid 
our  enlarging  further  upon  the  machinery  by  means  of 
which  such  outdoor  lying-in  services  are  conducted. 
Moreover,  descriptions  of  such  systems,  carried  on  in  Bal- 
timore, Philadelphia,  New  York,  and  Boston,  have  been 
sufficiently  dwelt  upon  during  the  past  ten  years. 

4.  Obstetric  Clinics. 

With  a  properly  equipped  operating  room  and  amphi- 
theatre, each  normal  or  abnormal  dehvery  in  the  ma- 
ternity may  be  made  the  occasion  for  an  pbstetric  clinic, 
all  the  students  on  the  premises  being  summoned  for  the 
occasion.  For  this  to  be  properly  carried  out,  it  should 
be  demanded  of  the  resident  staff  that  it  shall  also  be  a 
teaching  staff,  and  that  a  preliminary  history  of  the 
case,  in  each  instance,  should  be  concisely  stated,  as  well 
as  a  careful  exposition  of  each  step  of  the  labor  or  opera- 
tive procedure. 

Such  obstetric  clinics  could  readily  be  made  to  re- 
semble the  diagnosis  classes  held  abroad,  as,  for  in- 
stance, in  Munich  or  Prague,  where  parturient  women 
are  rolled  into  the  amphitheatre  from  the  ward  or  de- 
livery room,  and  tv,-o  students  are  called  down  from  the 
seats,  required  to  render  their  hands  and  forearms  ob- 
stetrically  clean,  in  the  presence  and  under  the  criticism 
of  the  instructor,  then  to  examine  the  case,  make  their 
diagnosis  of  pregnancy  or  labor,  presentation,  condi- 
tion of  OS,  membranes,  vagina,  vulva,  bladder,  rectum, 
and  hard  parts,  and  finally  undergo  questioning  from 
the   instructor   regarding   their   findings   in    the    case. 


13 


THE  BEST  METHOD   OF  TEACHINO   OBSTETRICS. 


Should  operation  or  interference  be  called  for  it  is  to  be 
performed  by  the  instructor;  but  should  the  case  prove 
a  normal  one,  the  student  may  be  permitted  to  complete 
the  case,  always  under  the  criticism  and  supervision 
of  the  instructor,  who  should  be  expected  to  address 
not  only  the  students  at  the  case  but  the  entire  au- 
dience. 

Many  points  of  practical  interest  connected  with  the 
management  of  the  second  and  tlaird  stages  of  labor,  the 
handling  of  the  cliild,  the  care  of  its  eyes,  the  administra- 
tion of  the  post-partum  douche,  the  watching  of  the 
fundus  uteri,  the  application  of  an  occlusion  dressing 
and  abdominal  binder,  may  be  brought  home  in  a  most 
thorough  as  well  as  interesting  manner. 

The  further  conduct  of  mother  and  cliild  may  rest 
with  the  two  students  confining  the  case,  and  they  should 
be  held  responsible  for  subsequent  departures  from  the 
normal  condition. 

5.  Theoretical  Lectures. 

Little  time  will  be  left  to  the  pupil  for  theoretical  in- 
struction during  his  maternity  service.  This  should 
precede  and  follow  his  practical  instruction. 

What  theoretical  teacliing  he  does  receive  at  tliis 
time  should  have  direct  bearing  upon  the  work  in  hand, 
and  should  rather  take  for  its  subject  abnormal  or  in- 
teresting cases  occurring  in  the  recent  service  of  the 
hospital. 

6.  Recitations. 

What  we  have  said  regarding  lectures  applies  equally 
to  recitations.  One  or  two  a  week,  however,  will  prove 
of  the  greatest  value  in  fixing  the  previous  practical 
work  of  the  student.  It  will  be  found  here  that  the  use 
of  those  aids  to  illustration  to  which  reference  has  already 
been  made  in  the  college  course  will  prove  of  untold 
value  in  firmly  establishing  the  principles  of  practical 
obstetrics  in  the  pupil's  mind. 

It  may  be  mentioned  here  that  most  of  these  aids, 
with  the  exception  of  the  wet  and  dry  specimens,  are  of 
such  a  nature  as  to  be  readily  kept  clean,  and  thus  free 
from  even  the  suspicion  of  danger  as  regards  their  use 
in  a  maternity. 

IV.  Theoretical  or  Didactic  Lectures  (illus- 
trative IN  character)  upon  Advanced  Obstet- 
rics. 

A  good  deal  has  recently  been  written  regarding 
the  passing  of  the  theoretical  or  didactic  lecture,  and 
the  fact  that  it  is  less  generally  made  use  of  than  here- 
tofore has,  in  the  foregoing  pages,  already  been  alluded 
to.  I  can  not  but  believe,  however,  that,  so  far  as 
obstetrics  is  concerned,  the  theoretical  lecture,  in  a  modi- 
fied form,  still  has  its  place  and  can  accomplish  much 
good. 

'  I  do  not  refer  to  the  old-fashioned  lecture  of  fifty- 
five  minutes,  devoted  to  rehearsing  the  course  of  a  dis- 


ease, interspersed  with  anecdote  and  clinical  experience 
of  the  speaker,  but  we  have  reference  to  a  lecture — theo- 
retical in  part,  to  be  sure,  but  partly  recitation  and  partly 
demonstration — which  deals  with  the  pathological  con- 
ditions of  more  advanced  obstetrics,  and  covers  sue! 
subjects  as  abortion  and  premature  labor,  extra-uterine 
gestation,  the  mechanics  and  physics  of  labor,  ruptures 
of  the  genital  tract,  puerperal  infection,  and  the  rarer 
forms  of  pelvic  deformity. 

Fifteen  minutes  at  the  commencement  of  such  a 
lecture  can,  to  advantage,  be  given  to  recitation  upon 
the  subject  of  the  preceding  lecture,  and  pathological 
specimens,  models,  the  blackboard,  and  the  lantern  and 
screen  are  not  to  be  neglected  as  means  of  demonstration 
and  illustration. 

In  conclusion,  I  desire  to  affirm  my  deep  con- 
viction that  the  subject  of  obstetrics  should  be  consid- 
ered in  no  sense  of  the  term  a  specialty,  but  a  depart- 
ment of  medicine  and  surgery. 

Further,  that  in  the  recitations,  demonstrations, 
laboratory  work,  clinics,  practical  bedside  instruction, 
and  theoretical  lectures,  already  alluded  to,  the  in- 
structor should  render  a  service  not  only  to  his  hsteners 
but  to  medicine  in  general,  by  rising  to  something  higher 
than  a  mere  perfunctory  performance  of  his  assigned 
duties,  and  impress  clearly  upon  his  class  the  fact  that 
midwifery  is  not  a  specialty  but  an  integral  part,  a  sub- 
division only  of  medicine  and  surgery. 

No  part  of  any  subject  can  be  properly  understood 
unless  it  is  studied  in  its  relations  to  the  whole.  The  in- 
terdependence and  intimate  relationship  of  these  three 
branches  can  not  be  too  clearly  brought  out  or  too  often 
insisted  upon.  The  light  shed  by  each  on  the  compli- 
cations of  the  others  is  too  bright  and  too  valuable  to 
be  lost  in  the  obscurity  of  prejudice  and  misconception. 

Obstetrics  to-day,  and  at  all  times,  should  be  taught 
equally  as  a  department  of  medicine  and  as  a  department 
of  surgery. 

The  day,  which  fortunately  for  suffering  women  has 
passed,  has  not  faded  from  the  memory  of  living  men — 
men  indeed  who  took  an  active  part  in  raising  midwifery 
to  its  present  position,  when  the  obstetrician  was  refused 
his  equal  place  by  his  brother  physicians  and  surgeons, 
using  the  words  in  their  narrowest  sense,  when  he  was 
not  permitted  to  operate  in  the  great  hospitals  of  the 
centres  of  population,  and  his  art  was  relegated  to  the 
place  it  occupies  now  in  the  hands  of  the  midwife!  With 
the  advance  of  medicine  in  general  during  the  last  half 
century  has  come  the  recognition  from  every  quarter 
of  the  kinship  of  these  allied  branches,  and  of  the  knowl- 
edge added  to  the  general  fund  by  the  obstetrician's 
painstaking  research.  It  is  just  these  facts  which  we 
claim  should  be  continually  brought  to  the  student's 
nttention,  in  order  that  he  may  not  in  his  future  career  * 


■Barnes.     Inaugural  Address.    Glasffnw  Medicaljmirnal,  Decemher, 


THE  BEST  METEOD   OF  TEAOHINQ   OBSTETRICS. 


13 


fall  into  the  error  of  regarding  midwifery  as  a  thing 
apart  from  general  medicine,  and,  further,  that,  if 
his  work  should  chance  to  lie  more  particularly  in 
other  fields,  he  may  carry  with  him  a  just  appreciation 
;of  an  art  in  which  he  has  been  at  least  thoroughly 
drilled. 

In  illustration  of  what  has  been  said,  it  may  not  be 
amiss  to  cite  a  few  instances  demonstrating  that  the 
physiological  and  pathological  states  of  pregnancy,  the 
puerperium  and  labor,  the  therapeutical  and  surgical 
measures  adopted  in  handling  them,  differ  certainly  not 
in  kind  from  these  conditions  found  elsewhere.  It  is 
only  that  the  greater  skill  of  the  accoucheur  after  long 
training  gives  him  an  advantage  readily  recognizable. 
The  toxiemia  of  pregnancy  is  toxaemia  still  in  spite  of 
its  graver  import,  perhaps,  in  the  danger  to  the  life  of 
mother  and  child,  and  its  indications  in  the  way  of 
treatment  are  the  same,  save  for  the  additional  obstetri- 
cal treatment.  Transient  glycosuria  disappearing  with 
the  termination  of  labor  or  the  onset  of  lactation,  jaun- 
dice, haemorrhage,  cardiac  hypertrophy,  thrombosis,  em- 
bolism, offer  no  essential  differences,  and,  further,  exhibit 
the  particular  morbid  condition  in  its  inception,  throw- 
ing a  light  on  its  astiology  often  obtainable  in  no  other 
way  (Barnes,  loc.  cit.).  We  are  too  prone  to  accept  the 
findings  in  the  dead  house  as  cause  rather  than  effect, 
and  to  neglect  the  opportunity  furnished  by  the  preg- 
nant state  to  observe  the  affection  at  its  outset  and  there- 
by discover  the  true  methods  of  prevention  and  cure. 
Metabolism,  in  both  its  forms,  here  furnishes  unequaled 
opening  for  study  to  the  physiologist.  There  is  much 
to  be  learned  from  observation  of  the  progress  of  inter- 
current disease — e.  g.,  tuberculosis,  under  the  intense 


vascular  and  nervous  strain  of  pregnancy.  The  same  is 
true  of  skin  affections,  both  as  to  their  nature  and  aeti- 
ology. The  so-called  "mask  of  pregnancy"  is  the 
chloasma  of  other  states;  herpes  gestationis  is  derma- 
titis herpetiformis;  and  here  the  dermatologists  may  find 
a  clew  to  the  origin  of  these  affections.  These  statements 
are  equally  applicable  in  the  province  of  surgery  and 
surgical  pathology. 

Gynaecology  may,  with  reason  and  right,  be  ranked 
as  a  specialty,  its  technical  procedures  entitling  it  to 
such  a  place,  but  not  so  obstetrics. 

Eepair  of  injuries  produced  by  labor,  instrumental 
or  manual  dilatation  of  the  cervix,  symphysiotomy,  cu- 
rettage, fall  more  naturally  to  the  obstetrician  only  be- 
cause of  his  skill  and  experience  in  their  operative  details, 
not  because  the  general  surgeon  is  not  entirely  com- 
petent to  perform  them. 

Certain  measures,  as  perforation,  cephalotripsy,  for- 
ceps and  version  operations,  manual  removal  of  the  pla- 
centa, decapitation,  evisceration,  correction  of  malpres- 
entations,  positions,  and  attitudes,  closely  approach  the 
border  line  of  specialism,  but  some  of  these  have  greatly 
fallen  into  disuse  since  the  introduction  of  other  per- 
fected operations  offering  a^  chance  of  life  to  the  child. 

Cesarean  section  itself  is  merely  the  removal  by  the 
knife  of  a  foreign  body  from  the  interior  of  a  hollow  vis- 
cus  whose  outlet  is  partially  occluded. 

This  argument  may  appear  at  first  sight  a  digression 
from  the  subject  in  hand,  but  reflection  will  show  not 
only  the  justice  but  the  necessity  of  its  introduction. 
His  student  career  is  the  time  when  the  physician  is  most 
impressionable,  and  when  facts  are  most  readily  brought 
home  and  fixed  in  his  mind. 


AIDS   m   OBSTETRIC   TEACHmG* 


PART    I. 


Jmxrodcction. 

The  underlying  principles  of  obstetrics  are  based 
upon  certain  recognized  and  well-known  laws  of  anato- 
my, physiology,  and  physics,  which  allow  of  a  wide  range 
of  illustration. 

Without  a  question,  the  best  single  method  for  the 
student  to  acquire  a  practical  and  lasting  knowledge 
of  midwifery  is  in  the  personal  and  actual  care  of  par- 
turient  and   puerperal   women — no   student,   however, 


especially  regarding  the  anatomical  and  mechanical  prin- 
ciples involved,  much  of  his  practical  experience  goes 
for  nothing  and  is  wasted  upon  him.  The  shortcomings 
of  the  theoretical  or  didactic  obstetric  lecture  have  in  the 
past  few  years  received  considerable  attention,  but  most  of 
those  who  have  arraigned  the  didactic  form  of  instruction 
in  the  strongest  terms  have  offered  us  no  substitute  other 
than  a  general  plea  for  more  practical  work. 

As  I  stated  in  the  preceding  paper,  I  believe  a  modi- 
fied theoretical  lecture  still  has  its  place  in  obstetric 


Pig.  9.—^  represents  the  model  finished  in  clay  and  ready  to  receive  the  first  coat  of  paper  strips  moistened  in  watet ;  B  represents  the  clay  model  covered  with 
the  first  layer  and  the  application  of  the  paper  strips  dipped  in  hot  carpenter's  glue;  ('shows  a  transverse  section  of  the  completed  paper  model,  with  its 
'   interior  filled  with  excelsior,  and  the  surface  ready  for  the  first  coat  of  paint. 


should  be  allowed  this  privilege  without  previous  train- 
ing— and  in  withessing  various  obstetrical  procedures  in 
a  clinic;  but  unless  his  mind  has  been  made  familiar 
with  the  main  principles  of  the  subject,  or  his  attention 
is  fixed  at  the  time  by  means  of  abundant  illustration, 


*  Read  before  the  American  Gynfecological  Society  at  its  twenty-liist 
annual  meetinp;,  New  York,  May  26, 189(5.  [The  illustrations  are  num- 
bered continuously  with  those  in  the  author's  previous  article  to  facili- 
tate reference  from  the  one  article  to  the  other.] 


teacliing — namely,  a  didactic  lecture  that  is  in  part  reci- 
tation, in  part  demonstration,  and  which  is  freely  and 
abundantly  illustrated  by  various  means,  some  of  which 
I  suggest  in  this  paper. 

Not  a  decade  ago  the  memory  was  the  only  faculty 
appealed  to  and  cultivated  in  the  teaching  of  obstetrics. 
The  student's  mind  was  made  the  recipient  of  isolated 
facts,  and  required  to  retain  them  by  brute  force  as  it 
were.  That  memory  has  its  place  and  is  an  important 
factor  we  make  no  question,  but  it  is  the  power  to  ob- 


AIDS  IN  OBSTETRIC  TE AGEING. 


15 


ve,  to  grasp,  to  comprehend,  to  utilize,  to  put  two  and 
,fO  together  and  reach  a  logical  conclusion — that  is  the 
fundamental  principle  of  practical  education. 

It  has  been  for  the  readier  and  better  cultivation  of 
those  two  faculties  of  the  mind,  so  essential  to  the  medi- 


of  the  instructor  in  the  recitation  room  may  be  abso- 
lutely wasted  upon  the  pupil,  whereas  were  simple  and 
familiar  objects  and  models,  which  possess  the  third 
dimension  of  space,  made  use  of  in  conjunction  with 
the  description,  the  subject  would  immediately  appeal  to 


f 


■Fig.  10.  Fin.  11.  Fig.  Vi. 

Fio.  10.— Non-gravid  uterus  (.3"  y.  2"  y.  1").    (Plaster  cast  from  Nature  ;  J  natu- 
ral size  ;  from  a  photograph.) 
Fig.  11.— Gravid  uterus  at  end  of  first  month  (3j"  x  2^"  x  Ij"),    Marked  an- 
tero-posterior  growth.     Piriform  shape   preserved.     Almost  cylindrical. 
■•""■  cast ;  i  natural  size  ;  from  a  photograph.) 

.id  uterus  at  end  of  second  month  (4i"  x  3,}"  v  3").     Further 
-rior  growth.    Pjriform  shape  still  preserved.    (Paper  model  ; 
i  uaiu  ...  sl.-^e  ;  from  a  photograph.) 

cal  student — namely,  the  reason  and  perception — that 
necessity  has  compelled  us  to  invent  these  various  aids  in 
obstetric  teaching  presented  to  the  American  Gynse- 
eological  Society  to-day.  The  medical  student  entering, 
for  example,  upon  his  recitation  course  in  obstetrics 
in  his  second  college  year,  will   of  necessity,  both  in  his 


Fig.  14. 

Fig.  1.3.— Gravid  uterus  at  end  of  third  month  (.5"  x  l"  x  3").  Pyriform 
shape  gradually  disappearing.  Shape  nearly  spherical.  (Paper  model ;  J 
natural  size  ;  from  a  photograph.) 

Fig.  14.— Gravid  uterus  at  end  of  fourth  month  (6"  x  5"  x  4").  Marked 
ovoid.  Anterior  surface  round  as  a  ball ;  posterior  surface  flattened.  Cor- 
pus uteri  furnishes  principal  element  of  growth.  Tubes  considerably  below 
the  horns.  Size  and  shape  influenced  by  fcetus,  placenta,  liquor  amnii,  and 
disease.    (Paper  model ;  i  natural  size  ;  from  a  photograph.) 

the  student,  new  interest  would  be  awakened,  and  the 
facts  in  question  be  rendered  so  plain  and  simple  as  not 
readily  to  be  misunderstood  or  forgotten. 

Diagrams  fail  because  they  are  unreal,  because  they 
are  not  readily  understood,  because  the  anatomical  rela- 
tionships are  obscured,  because  only  one  surface  of  the 


Fig.  15. 


Fig.  16. 


Fig.  16.— Gravid  uterus  at  end  of  fifth  month  (7"  x  6"  x  b").  Characteristics 
same  as  at  end  of  fourth  month.  (Paper  model ;  i  natural  size ;  from  a 
photograph.) 

Fig.  16.— Gravid  uterus  at  end  of  sixth  month  (8i"  x  6J"  x  6").  Ovoid  grad- 
ually becoming  egg-shaped.  Posterior  wall  flattened  by  spinal  column. 
Tubes  considerably  below  horns.  Size  and  shape  influenced  by  foetus,  pla- 
centa, liquor  amnii,  and  disease.  (Paper  model ;  J  natural  size ;  from  a 
photograph.) 

reading  and  his  class-room  work,  encounter  many  new 
and  unfamiliar  words,  or  many  which  have  heretofore 
been  used  in  quite  another  sense,  and,  moreover,  to  such 
an  extent  that  he  completely  fails  to  grasp  the  underly- 
ing principles  that  they  are  intended  to  convey.  Thus, 
an  elaborate  description  in  the  text-book  or  ou  the  part 


Pig.  17.— Gravid  uterus  at  end  of  seventh  month  (lOj"  x  7J"  x  61").  Egg- 
shaped.  Broadest  just  below  fundus.  Longitudinal  axis  predominates. 
Posterior  wall  flattened  by  spinal  column.  Tubes  still  farther  below  horns. 
Size  and  shape  influenced  by  fojtua,  placenta,  liquor  amnii,  and  disease 
(Paper  model ;  i  natural  size  ;  from  a  photograph.) 


object  is  presented.  The  model  succeeds  since  the  re- 
verse obtains.  Take,  for  example,  the  flattened  pelvis  of 
rhachitis.  The  student's  interest  is  immediately  awak- 
ened and  held  if  such  a  pelvis  be  placed  in  his  hands 
with  the  request  to  point  out  the  departures  from  the 
normal  condition. 


16 


AIDS  IN  OBSTETRIC  TEAGEINO. 


Injuries  to  the  pelvic  floor  become  much  more  real  |  So  in  the  description  of  the  involution  of  the  puer- 
and  easily  understood  when  reproduced  in  casts,  with  |  perium  and  the  relations  of  the  uterus  to  the  surrounding 
real  sutures  in  place,  than  by  chalk  on  the  blackboard  I  parts,  paper  reproductions  of  frozen  sections  will  render 
or  diagrams  in  text-books.     So,  too,  the  history  of  the  |  us  great  service  in  holding  the  student's  attention  and 


Pig.  18. 

Fig.  18.— Gravid  uterus  at  end  of  eighth  month  (lU"  x  8"  x  7").  Character- 
istics same  as  at  end  of  seventh  month.  (Paper  model ;  i  natural  size';  from 
a  photograph.) 

Fig.  19.— Gravid  uterus  at  end  of  ninth  month  (13"  x  9J"  x  8i").  Ovoid- 
shaped.  Longitudinal  axis  predominates.  Broad  fundus.  Anterior  surface 
more  convex  than  heretofore.    Posterior  depression  caused  by  lumbo-sacral 

progress  of  pregnancy  becomes  simplified  with  models 
of  the  pregnant  uterus  to  illustrate  it;  the  changes  in  the 
vaginal  portion  of  the  cervix,  the  supravaginal  portion, 
the  internal  and  external  os,  as  well  as  the  mechanism 
of  dilatation,  and  the  passage  of  the  fcetus  through  the 


Fig.  20.— Vertical  mesial  section  of  the  parturient  canal  at  the  end  of  the  stage 
of  dilatation,  from  a  woman  who  died  during  labor.  (After  Karl  Braune  ; 
weight,  one  pound  and  three  quarters.    Paper  model.    From  a  photograph.) 

OS  and  ostium  vaginae,  become  realities  never  to  be  for- 
gotten, with  a  series  of  flexible  models  to  represent  the 
same,  which  the  student  is  called  upon  to  examine  and 
demonstrate  personally. 


Fig.  19.- 
angle.  Fundus,  rarely  regular,  depends  on  posture  of  foetus.  Festal  head 
causes  increased  development  of  anterior  part  of  lower  uterine  segment. 
"Sacciform  dilatation  of  lower  uterine  segment."  Size  and  shape  influ- 
enced by  fcetus,  placenta,  liquor  amnii,  and  disease.  (Paper  model ;  i  nat- 
ural size  ;  from  a  photograph.) 


fixing  the  facts  regarding  them.  Moreover,  subsequent 
practical  work  in  the  lying-in  hospital  and  outdoor  ma- 
lernity  service  becomes  not  only  more  profltable  and  in- 
structive to  the  student,  but  safer  for  the  patients  after 
such  ocular  demonstrations  of  familiar  obstetric  prin- 


FiQ.  21.— Same  as  Fig.  20,  with  fcetal  cadaver  placed  in  right  anterior  position 
of  the  vertex.  Head  well  engaged,  internal  rotation  just  beginning.  (Paper 
model;  from  a  photograph.) 

ciples.  Again,  we  have  found  some  of  these  aids — as  the 
leather  puerperal  uterus,  paper  models  of  pregnant  and 
puerperal  uteri,  composition  cervices,  and  perineal 
lacerations — of  lasting  and  practical  value  in  the  instruc- 


AIDS  IN  OBSTETRIO  TEACHING. 


17 


tion  in  obstetrics  of  nurses  still  in  the  training  school  of  I  the  aids  herein  set  forth,  either  in  the  delivery  or  lec- 
a  general  or  maternity  hospital.     We  have  repeatedly  |  ture  room,  are  rendered  much  more  interesting,  profit- 


FiG.  22.— Diagrammatic  \ertical  medial  section  ol  piutunent  canal  at  bcj^inniug 
of  the  first  stage  of  labor  to  illustrate  \aginal  and  eupriviginal  portions  of 
the  cervix.  Useful  to  illustrate  poitnre  presentation  and  position  of  the 
foetus,  use  of  vaginal  tampon,  varieties  of  cervical  dilators,  placenta  prsevia, 
and  many  other  conditions.    (Paper  model.) 


Fig.  23. — Same  as  Fig.  22  ;  illustrates  fcetal  cadaver  in  right  anterior  position 
of  the  vertex,  central  placenta  previa,  Barnes's  bag,  and  vaginal  tamponade 
in  position.  DemoDetratesdangers  of  the  Barnes's  bag  producing  premature 
separation  of  the  placenta  beyond  the  ring  of  the  internal  os  and  the  result- 
ing internal  or  concealed  ho3morrhage  by  reason  of  the  distal  extremity  of 
the  Barnes's  bag  projecting  too  far  into  the  cavity  of  the  lower  uterine  seg- 
ment.   (Paper  model  ;  from  a  photograph.) 


observed,  by  reason  of  the  slight  knowledge  of  anatomy, 
physiology,  and  histology  which  these  pupil  nurses  pos- 
sess, that  demonstrations  supplemented  by  the  use  of 


able,  and  instructive,  than  a  mere  dry  recital  of  facts. 
This  is  especially  true  in  hospitals  in  which  practically 
no  maternity  service  is  given  to  the  nurses,  or  in  those 


.  3-(. —Diagrammatic  verUcal  mesial  section  of  parturient  ( 
demonstrationB  of  intra-ulcrinc  n 


aJ  at  end  of  firHtHtage  of  labor.    The  uterine  cavity  is  covoi'ed  by  a  netting  so  as  to  permit  of  ocular 
lipuiations.    Illustrates  internal  direct  podalic  version.    (Paper  model.) 


18 


AIDS  IN  OBSTETRIC  TEACHING. 


where  the  rules  of  the  institution  debar  the  nurse  from 
actually  conducting  the  confinement,  or  even  making  a 
vaginal  examination. 

Objection  is  occasionally  raised,  justly  or  unjustly, 
that  general  obstetric  demonstration,  apart  from  the  bed- 
side or  clinic,  carries  with  it  the  necessity  of  handling 
wet  and  dried  anatomical  material — fcetal  cadavers,  for 
instance — and,  consequently,  a  suspicion  of  uncleanli- 
ness. 

Not  the  least  advantage  of  the  greater  number  of  the 


specimens  of  pelvic  deformity,  and  an  interchange  of 
such  models,  together  with  their  clinical  history,  may 
accomplish  much  to  raise  the  standard  of  obstetric  in- 
struction. 

I'ROPEE      PLACE      FOE      MODELS CAUTIONS      EEGAEDINQ 

THEIE    USE. 

I  desire  at  the  outset  emphaticaly  to  disclaim  any 
intention  of  impljdng  or  suggesting  that  the  aids  in 
obstetric  teaching  herein  described  and  illustrated  are 


Fig.  25. 
Mechaniem  of  cervical  dilatation  i 


primiparee  (diagrammatic).    (Paper  models  ;  from  a  photograph.) 


aids  in  obstetric  teaching  herein  described  is  to  be  found 
in  the  fact  that  by  reason  of  their  composition  they  may 
be  made  and  kept  obstetrically  clean — no  small  advan- 
tage, since  we  often  desire  to  use  the  same  at  the  bedside 
or  in  the  obstetric  clinic. 


in  any  sense  to  replace  practical  bedside  instruction. 
These  aids  I  offer  as  auxiliaries,  as  adjuncts  for  more 
instructive  and  interesting  obstetric  recitations,  demon- 
strations, theoretical  lectures,  clinics,  examinations  of 
pregnancy,  and  ward  instruction  in  maternity  hospitals. 


Mechanism  of  cervical  dilatation  i 


Fig.  S8. 
mltlparae  (diagrammatic).    (Paper  models  ;  from  a  photograph.) 


Much  that  I  present  in  these  pages  is  suggestive  and 
rudimentary  in  character;  much,  we  feel,  can  and  will 
be  improved  upon  as  time  and  opportunity  ofEer.  For 
example,  I  beg  leave  to  suggest  that  plaster  molds  be 
taken  of  specimens  of  pregnant  uteri  of  known  months 
of  gestation,  so  that  from  these  subsequently  any  desired 
number  of  papier-mache  models  may  be  reproduced  for 
exchange  among  museums  and  obstetric  teachers.  The 
same  plan  may,  I  believe,  be  pursued  in  the  case  of 


I  can  confidently  assert,  as  the  result  of  several 
years'  experience  in  the  use  of  such  aids,  that  they  throw 
new  light  upon  many  physiological  and  mechanical  prob- 
lems of  midwifery,  and  that  they  moreover  lend  new 
interest  to  many  obstetric  subjects,  which,  by  reason  of 
their  obscureness  and  dryness,  have  in  the  past  proved 
more  than  stumbling  blocks  to  students,  and,  I  may 
truthfully  add,  to  practitioners  as  well. 

It  can  not  be  too  strongly  insisted  upon  that  great 


AIDS  IN  OBSTETRIC  TEACHING. 


19 


Fig.  30. — Vertical  mesial  seclion  of  piKn-ueral  iiterii8  live  niiuutes  after  delivery. 
Patient  died,  heart  disease.  (After  Webster  ;  paper  model ;  from  a  pho- 
tograph.) 


Fig.  29.— Vertical  mesial  section  of  the  pregnant  uterus  at  the  beginning  of  the 
fifth  month  of  gestation.    (Paper  model ;  from  a  photograph.) 


Kio,  yj.— Vertical  menial  Hc-ction  of  puerperal  uterus  ECConOuay  of  pueiperium.        Fia.  32.— Vertical  mcBial  section  of  puerperal  uterus  three  days  after  labor^ 
Patient  died  of  eclampsia  thirty-six  hours  after  labor,    (After  Webster;  Patient  died  of  acute  yellow  atrophy.    Nearly  full  term.    (After  Webster ; 

paper  model ;  from  a  photograph.)  paper  model ;  from  a  photograph.) 


20 


AIDS  IN  OBSTETRIC  TEACHING. 


care  must  be  employed  in  the  selection  and  use 
of  models  as  aids  in  obstetric  teaching.  Their 
proper  place  must  be  constantly  kept  before  us, 
and  wliere  reproductions  from  Kature  in  paper, 
plaster,  composition,  or  rubber  are  employed, 
we  have  found  it  safer  and  generally  more  sat- 
isfactory to  produce  the  natural  size  of  the  ob- 
ject, as  by  enlarging,  the  subject  may  become 
merely  grotesque,  or  even  convey  a  false  impres- 
sion. A  wrong  impression,  moreover,  readily 
acquired,  is  often  less  easily  corrected  in  this 
connection. 

If  proper  care  is  taken  in  the  selection  and 
preparation  of  models,  no  false  or  exaggerated 
impression  will  be  conveyed,  and  the  produc- 
tion of  models  in  three  dimensions  of  space,  at 
which  we  always  aim,  secures  for  us  a  means  of 
ocular  demonstration  and  illustration,  which 
diagrams  and  charts,  be  they  ever  so  beautifully 
executed,  or  even  blackboard  illustration  with  an 
abundant  supply  of  colored  chalk,  can  never 
equal.  Diagrams  are  unsatisfactory;  they  soon 
become  tiresome  to  the  student,  and  they  may 
be  misleading  because  of  the  loss  of  the  third 
dimension  of  space. 

The  attempt  on  the  part  of  the  student  to 
acquire  a  correct  and  clear  idea  of  certain  funda- 
mental obstetric  principles  from  a  study  of  a 


J.  33.— Vertical  mesial  sectior 
died  of  heart  disease.    (Afte 


of  puerperal  uterus  fifteen 
Webster  ;  paper  model ;  fri 


days  after  liiimr. 
>m  a  photograph. 


Fig.  35.— Complete  rupture  of  the  uterus  involving  left  lateral  and  posterior 
walls  and  extending  from  the  contraction  ring  almost  to  the  external  OS, 
which  latter  is  intact.  Also  complete  rupture  of  posterior  vaginal  wall  just 
below  external  ring,  opening  into  Douglas's  pouch.  (After  a  specimen  in 
the  Museum  of  the  Munich  Prauenklinik  ;  paper  model ;  from  a  photo- 
graph.) 

Fig.  36.— Complete  rupture  of  the  left  posterior  wall  of  the  uterus,  extending 
from  the  contraction  ring  downward  and  inward  across  the  lower  uterine 
segment,  through  the  external  os,  and  some  distance  down  the  posterior 


FiQ.  87. 

vaginal  wall.  This  illustrates  a  particularly  dangerous  form  of  rupture  of 
the  genital  tract,  because  of  the  possibility  of  direct  infection  of  the  peri- 
toneal cavity  by  the  vaginal  secretions.  (Paper  model ;  from  a  photo- 
graph.) 
Fig.  37. — Transverse  rupture  of  the  uterus  through  the  lower  uterine  segment 
at  a  point  halfway  between  the  contraction  ring  and  the  external  os.  Can- 
cer of  the  cervix.  Vertical  mesial  section.  (Paper  model ;  from  a  photo- 
graph.) 


AIDS  IN  OBSTETRIC  TEACHING. 


21 


series  of  illustrations  in  his  text-book  or  in  the  lec- 
ture room  is  very  apt  to  result  in  a  condition  of  be- 
wilderment on  his  part,  which  could  readily  have  been 
avoided  by  the  free  use  of  a  few  simple  models.  With 
such  models,  recitations  and  demonstrations  to  classes 
divided  into  easily  handled  sections  can  be  made  to 


pelv 


;)ii  ul'  imi'rpLT^l  utei-118  auir  uorn  at\er  labor. 
:  Stratz  ;  paper  model  ;  from  a  photograpli.) 


result  in  much  practical  gain  to  the  student,  who  has 
up  to  this  point  obtained  his  knowledge  of  obstetrics 
from  text-books  merely. 


VARIOUS    KINDS    OF    AIDS. 


For  purposes  of  convenience  we  shall  enumer- 
ate and  describe  the  several  kinds  of  aids  to  obstetric 
teaching  included  in  this  paper  under  the  following 


I.  Plaster  models. 

II.  Paper  reproductions  of  clay  models  and  plaster 
its. 

III.  Composition  models. 

IV.  Miscellaneous  models  and  aids. 

V.  Electro-plated  casts  and  models. 


I.  Plaster  Models. 

Experience  has  taught  us  that  plaster  models  per  se 

have  a  very  limited  field  in  this  direction.    Unless  the 

subjects  be  small  and  compact,  the  tendency  of  the  plaster 

to  break,  and  the  excessive  weight  in  the  case  of  the  large 

ones,  are  decided  objections. 

Plaster,  however,  will  answer  very  well  for 
the  smaller  uteri  of  the  early  months,  and  has 
been  of  service  to  us  in  securing  first  impressions 
of  lacerations,  pregnant  uteri,  external  genitals, 
etc.,  which  are  su.bsequently  reproduced  in  paper, 
composition,  rubber,  or  rendered  serviceable  and 
durable  by  electro-plating  with  copper,  as  de- 
scribed hereafter. 

II.  Paper   Reproductions    of    Clay    and   Plaster 
Models. 

After  experimenting  with  various  kinds  of 
papier-mache,  papier-mache  compositions,  and 
modified  plaster,  we  have  found  the  method 
proposed  by  Dr.  W.  6.  Thompson  *  as  best 
suited  for  our  purpose,  because  of  the  lightness, 
durability,  and  cheapness  of  the  models  made  by 
this  process. 

In  addition  to  the  plaster  model,  all  that  we 
require  is  an  abundant  supply  of  old  newspapers, 
some  carpenter's  glue,  shellac,  or  a  good  varnish, 
and  some  ready-mixed  paints.  The  clay  model 
or  plaster-cast  model  having  been  made  (see  Fig. 
9,  A),  it  is  first  covered  on  one  side  with  a  sin- 
gle layer  of  small  pieces  of  newspaper  (two  by 
four)  moistened  in  cold  water  (see  Fig.  9,  B). 
Every  portion  of  the  model  or  cast  is  thus  cov- 
ered with  a  single  layer,  and  rapidly  laid  upon 
this  layer  successive  layers  of  paper  dipped  in 
hot  glue  are  added.  By  means  of  a  fiat  brush 
....  i  time  is  saved  by  painting  the  glue  over  the  sur- 
racted  f^gg  j^jjj^  rapidly  laying  the  strips  of  paper  upon 
it.  Special  care  is  needed  with  the  last  layer 
of  strips  only,  in  order  to  secure  a  smooth  sur- 
face (see  Fig.  9,  0).  The  number  of  layers  and  sub- 
sequent thickness  of  the  wall  should  depend  upon  the 
character  and  size  of  the  model.  In  large  models  wire 
gauze,  strips  of  cheese  cloth,  cardboard,  and  even  thin 
slabs  of  pine,  may  with  advantage  be  incorporated  with 
the  paper  and  glue  to  add  stability.  The  casing  is  now 
allowed  to  dry  thoroughly  upon  the  clay  or  plaster 
mold,  and  is  then  removed  either  entire  or  in  two  or 
more  sections  when  the  former  can  not  be  done  (see  Fig. 
9,  C). 

If  the  model  represents,  for  instance,  a  sagittal  sec- 
tion, the  interior  is  now  carefully  stuffed  with  loose  news- 
paper or  excelsior,  and  a  back  added  by  means  of  larger 

*  The  Use  of  Automatic  and  other  Models  in  teaching  Pliysiology, 
Researches  of  the  Loomis  Laboratory,  vol.  ii,  1892. 


•22 


AIDS  IN  OBSTETRIC  TEAQIIINQ. 


pieces  of  newspaper,  strengthened  with  cheese  cloth,  glued 
in  the  same  manner  as  the  above  (see  Fig.  9,  C).  When 
tliis  has  thoroughly  dried,  a  couple  of  thick  coats  of  paint 
are  applied,  to  represent  the  object,  and  the  whole  shel- 
lacked or  varnished.  For  accuracy  in  the  reproduction 
of  frozen  sections  (see  Figs.  20,  29,  30,  31,  32,  33,  and 
34),  diagrams  of  sagittal  sections  (see  Figs.  23,  23,  24,  25, 
26,  27,  and  28),  pathological  specimens  (see  Figs.  35,  36, 
and  37),wehavephotographed  thecutsor  rephotographed 
the  photographs,  then  with  an  enlarging  lantern  thrown 
the  outline  of  the  figure  upon  a  sheet  of  the  thinnest 
tissue  paper  until  the  desired  size  was  obtained,  and 
outlined  the  object  with  a  heavy  pencil.  Then,  placing 
the  paper  upon  the  smooth  layer  of  clay,  the  modeling  is 
done  directly  through  the  paper,  the  moisture  of  the 
clay  finally  absorbing  the  tissue  paper.  Thus,  absolute 
accuracy  of  detail  and  relationship  can  be  obtained. 
The  reproductions  of  Webster's  frozen  sections  (Fig. 
20)  were  made  in  this  manner. 

"  When  finished,  the  model  becomes  as  hard  as  board 
and  it  possesses  great  advantage  over  papier-macM,  which 
is  more  expensive  and  usually  brittle,  unless  subjected 
to  great  pressure. 

"  This  new  composition  is  smooth  and  very  hard, 
watertight  (for  cold  water),  it  never  warps,  breaks,  or 
cracks,  and  when  painted  it  is  difficult  to  believe  that  it 
has  been  made  of  such  cheap  material." 

An  almost  endless  variety  of  anatomical  and  physio- 
logical obstetrical  models  may  be  thus  secured. 

Transverse  and  sagittal  sections  are  reproduced,  aF 
shown  above.  Where  oval  or  round  objects,  as  pregnant 
uteri  or  tumors,  are  to  be  reproduced,  the  entire  speci- 
men is  covered  with  the  paper  as  above  described,  allowed 
to  dry,  then  cut  in  halves,  the  clay  or  plaster  allowed  to 
drop  out,  and  the  two  shells  stuffed  with  excelsior  and 
glued  together  with  several  layers  of  paper  strips  over- 
lapping at  the  seam. 

1.  Size  and  shape  of  the  uterus  during  the  successive 
months  of  gestation. 

These  paper  models  here  illustrated  are,  with  the 
exception  of  the  normal  uterus,  not  taken  from  Nature, 
but  are  founded  upon  the  collective  descriptions  and 
average  measurements  given  by  Webster,  Hart  and  Bar- 
bour, Eibemont-Dessaigners,  Farr  and  Tanner. 

Should  opportunity  offer,  more  valuable  and  precise 
models  could  undoubtedly  be  produced  by  making,  im- 
mediately after  death,  plaster  casts  of  gravid  uteri, 
and  then  subsequently  paper  reproductions  of  the  same. 
We  would  offer  here  as  a  suggestion,  as  we  do  in 
another  place,  that  casts  of  such  uteri  from  the  cada- 
ver be  made  which  can  subsequently  be  reproduced  in 
paper  and  exchanged  among  obstetric  teachers  and  mu- 
seums. Many  are  the  uses  to  wliich  such  paper  uteri 
may  be  put:  The  height  of  the  fundus  in  the  several 
months  in  and  out  of  the  pelvis;  the  changes  in  the 
shape  of  the  fundus  and  lower  uterine  segment,  and 
their  influence  upon  the  attitude,  presentation,  and  posi- 


tion of  the  foetus;  placental  insertion;  physiology  and 
pathology  of  pregnancy  and  labor;  and  many  other  con- 
ditions that  will  constantly  suggest  themselves,  so  that 
such  models  will  be  in  almost  constant  use  during  a 
course  of  obstetric  teaching. 

2.  Vertical  mesial  sections  of  uteri  at  term;  mechan- 
ism of  cervical  dilatation. 

Fig.  20  is  a  reproduction  in  paper  of  Braune's  frozen 
section  of  the  parturient  uterus  at  the  end  of  the  first 
stage,  and  Fig.  21  is  the  same,  with  a  foetal  cadaver  intro- 
duced to  illustrate  presentation  and  position. 

Fig.  22  is  a  diagrammatic  representation  of  a  vertical 
mesial  section  of  a  uterus  at  the  beginning  of  the  firsl 
stage  of  labor,  before  the  disappearance  of  the  supra- 
vaginal portion  of  the  cervix.  The  uses  to  which  these 
two  models  can  be  put  are  almost  endless,  and  students 
in  a  short  time  can  be  brought  to  appreciate  obstetric 
conditions  and  situations  wloich  hours  of  explanation  for- 
merly were  required  to  elucidate. 

For  example,  the  model  of  Fig.  20  can  easily  be  made 
to  demonstrate  the  curve  of  the  parturient  canal,  nor- 
mal and  abnormal  attitude,  presentation  and  position 
of  the  fcetus,  displacement  of  the  small  parts,  and  so  on. 

So  the  diagrammatic  model  of  the  uterus  (Fig.  22), 
with  its  cervical  canal  dilated  to  the  size  of  one  finger, 
has  proved  of  value  in  exhibiting  various  forms  of  cer- 
vical dilators,  as  Tarnier's  Barnes's,  Champetier  de 
Ribes's,  and  others,  and  the  advantages  and  the  disad- 
vantages of  each;  the  varieties  of  placenta  previa;  the 
uses  and  action  of  the  vaginal  tampon;  and  many  other 
conditions  that  will  suggest  themselves  to  the  instructor. 

Fig.  24  also  represents  a  diagrammatic  vertical  mesial 
section  of  the  uterus,  its  open  side  fitted  with  netting 
in  order  to  retain  the  fretal  cadaver  or  puppet  during 
demonstrations  of  the  intra-uterine  manipulations  ac- 
companying different  varieties  of  version,  reposition  of . 
prolapsed  small  parts,  correction  of  malpositions  and 
postures. 

The  models  representing  cervical  dilatation  in  primip- 
arse  and  multiparffi,  in  Figs.  25  to  28,  will,  to  a  more  lim- 
ited extent,  be  found  useful. 

3.  Eeproductions  of  frozen  sections  of  gravid  and 
puerperal  uteri. 

It  has  been  with  some  hesitation  that  I  have  at- 
tempted the  reproduction  of  the  frozen  sections  of  Web- 
ster and  Stratz  for  fear  that  something  of  the  original 
would  be  lost  or  distorted  in  the  paper  model.  We 
have  therefore  confined  our  work  to  the  grosser  ones, 
as  the  puerperal  uteri  of  Webster.  In  only  one  instance 
have  I  attempted  to  produce  a  model  of  the  gravid 
uterus  and  its  contained  ovum  (Fig.  29),  and  the  result 
was  not  altogether  satisfactory.  For  such  illustrations 
quite  as  much  can,  we  believe,  be  accomplished  by  dia- 
gram. 

The  series  of  models  representing  involution,  posi- 
tion and  relationships  of  the  puerperal  uteri,  after  Web- 
ster's frozen  sections,  we  have  found  of  marked  aid  in 


AIDS  IN  0B8TETRI0  TEAOJIINa. 


23 


demonstrating  many  conditions  associated  not  only  with 
the  physiology,  but  also  the  pathology  of  the  puer- 
perium  *  (Figs.  30  to  34). 

*  Barbour,  in  the  Edinhurgh  Medical  Journal^  October  18,  1895,  in 
a  series  of  papers  upon  the  study  of  frozen  sections,  after  passing  in 
review  the  various  sections  described  by  different  investigators,  makes 
an  estimate  of  the  value  of  this  method  of  study,  as  follows :  Barbour 
considers  that,  by  means  of  such  sections,  we  have  gained  most  in 
knowledge  regarding  the  birth  canal.     He  acknowledges  the  limitations 


4.  Eupture  of  the  uterus  and  vagina  during  labor. 

These  models  were  made  with  a  view  to  showing 
the  most  frequent  site  of  uterine  rupture,  the  relation  of 
the  rupture  to  the  contraction  ring  and  external  os, 
and  the  greater  danger  of  infection  when  the  tear  in- 
volves the  vagina  as  well  as  the  uterus. 

which  are  inevitable  in  such  study,  but  considers  that  we  have  by  this 
method  acquired  ideas  which  have  revolutionized  our  conceptions  of 
study. 


AIDS  m  OBSTETRIC  TEACHING. 


PART   II. 


III.  Composiiion  Models. 
In  casting  about  some  time  since  for  a  cheap  substi- 
tute for  rubber  in  the  construction  of  models,  our  atten- 
tion was  directed  to  the  glue  composition  which  model- 
ers and  plaster  workers  have  for  years  made  use  of  in 


the  manufacture  of  their  interior  decorations.  Our  aim 
was  to  produce  flexible  cervices  and  pelvic  floors  by  this 
method,  and  after  much  experimenting  we  were  com- 
pelled to  confine  our  models  in  composition  here  de- 
scribed to  a  series  of  parturient  cervices  in  different 


EXjOS. 


IW.OS, 


SVc, 


EX.OS. 


Fifi.  38.— Cer 


Fig.  88. 
1  latter  part  of  gestation  ( 


Fig.  40. 


'  at  beginning  of  labor.  Vaginal 
and  supravaginal  portions  of  cervix  unchanged,  v.y  cuif  of  vagina  ;  ex.  os., 
external  os  and  inf  ravagiual  portion  of  the  cervix  ;  c.  v.  J.,  cervico-vaginal 
junction  ;  5.  v.  c,  supravaginal  portion  of  cervix  ;  in.  os.,  internal  os  ;  I.  u.  s., 
lower  uterine  segment.  (Composition  model ;  from  a  photograph.) 
Fig.  39. — Lower  uterine  segment  during  labor.  Cervix  in  progress  of  being 
drawn  up  into  the  body  of  the  uterus.  Supra-  and  infravaginal  portions  of 
the  cervix  still  present,    v.,  cuff  of  vagina ;  ex.  os.,  external  os  and  infra- 


vaginal  portion  of  cervix  ;  c.  v.  J.,  cervico-vaginal  junction  ;  .*;.  i\j.,  supra- 
vaginal portion  of  cervix  ;  in.  os.,  internal  os  :  I.  v.  s.,  loweruterine  segment 
(Composition  model :  from  a  photograph.) 
Fig.  40. — Lower  uterine  segment  during  labor,  v.,  cuff  of  vagina ;  ex.  os.,  ex 
ternal  os,  infravaginal  portion  of  cervix  has  disappeared  ;  c.  v.j  ,  cervico- 
vaginal  junction  ;  s.  v.  c,  supravaginal  cervix,  small  portion  only  remaining  ; 
in.  OS.,  internal  os ;  I.  n.  s.,  lower  uterine  segment.  (Composition  model ; 
from  a  photograph.) 


IN. OS 

Fig.  41.  Fig.  ■12. 

Fig.  41.— Lower  uterine  segment  during  labor.  Os  uteri  in  progress  of  dilata- 
tion. Supra-  and  infravaginal  portions  of  the  cervix  have  disappeared.  Os 
one  third  dilated,  v.,  cuff  of  vagina;  ex.os.,  external  os;  u  v.  j.,  utero- 
vaginal junction  ;  I.  u.  «.,  lower  uterine  segment.  (Composition  model ; 
from  a  photograph.) 

Flo.  42. — Lower  uterine  segment  during  labor.    Os  uteri  almost  fully  dilated. 


Fig.  43. 


v.,  cuff  of  vagina;  ex.  os.,  external  os;  u.  v.  J.,  utero-vaginal  junction; 
I.  V.  «.,  lower  uterine  segment.  (Composition  model ;  from  a  photograph.) 
Fig.  43. — Lower  uterine  segment  at  completion  of  first  stage  of  labor.  Os  uteri 
completely  dilated,  v.,  cuff  of  vagina ;  ex.  os.,  border  of  external  os, 
scarcely  perceptible  ;  v.  v.j.y  utero-vaginal  junction.  (Composition  model  ; 
from  a  photograph.) 


Aim  IN  OBSTETRIC  TEACHmQ. 


25 


it  is  expelled.  Subsequent  contrac- 
tion and  hardening  of  the  model  will 
depend  upon  the  completeness  with 
which  the  water  passes  off  at  this 
time.  The  time  ■  required  for  this 
heating  process  will  depend  upon  the 
size  of  the  mass  and  the  amount  of 
the  contained  water. 

When  ready  to  pour,  the  mass 
should  be  almost  free  from  water,  of 
a  thick,  creamy  consistence,  and  no 
small  pieces  of  glue  should  remain 
unmelted. 

At  this  time  any  desired  color  may 
be  imparted  to  the  composition  by 
the  addition  of  a  strong  alcoholic  so- 
lution of  any  of  the  aniline  series. 

Preparation  of  the  Mold. — Given 
a  clay,  plaster,  papier-mache,  or  other 
model,  which  it  is  desired  to  repro- 
duce in  glue  composition,  it  is  first 
necessary  to  construct  a  mold.  For 
the  composition  cervices  (Kgs.  38  to 
43)  the  lower  segment  of  the  papier- 
mache  model  of  the  pregnant  uterus 
at  the  eighth  month  (Fig.  18)  was 
used.  A  negative  mold  of  the  lower 
third  of  this  uterus  was  taken  in  plas- 


FiG.  44. — Instrumental  dilatation  or  i 
the  introduction  of  bougies  tor 
from  a  photograph.) 


aii'iil  o.~  preparatory ]to  further  manual  dilatation,  i^auze  packing, 
iudmjtiou  of  labor,  or  cervical  dilators.    (Composition  model ; 


stages  of  dilatation  (Figs.  38  to  43),  and,  after 
all,  fall  back  on  rubber  for  the  pelvic  floor  (Fig. 
63). 

The  composition  mixture  finally  adopted  was 
one  of  Cooper's  A-1  glue  and  pure  glycerin,  the 
same  as  that  used  by  modelers  and  plaster  work- 
ers, with  the  addition  of  glycerin,  to  give  the 
mass  lasting  flexibility,  the  glue  being  chosen 
in  preference  to  gelatin  because  of  its  being 
cheaper.  The  proportion  of  the  glue  and  gly- 
cerin will  depend  upon  the  degree  of  flexibility 
of  the  model  desired.  I  have  found  that  a  pro- 
portion of  one  part  of  glue  to  one  of  glycerin 
gives  the  proper  flexibility  to  the  mass  for  the 
cervices  subsequently  described. 

The  method  is  very  simple  and,  aside  from 
the  glycerin,  very  cheap.  The  glue  is  first 
soaked  in  cold  water  until  moist;  the  excess  of 
water  is  then  removed  by  filtering  through  stout 
burlap  or  other  filtering  material.  Then,  placed 
over  a  water  bath,  the  glue  is  melted,  the  gly- 
cerin added,  and  the  mass  allowed  to  boil  until 
most  of  the  small  amount  of  water  contained  in 


Fio.  4.').— Digital  dilatation  of  the  parturient  08. 
supravaginal  portions  of  the  cervix  present, 
graph.) 


Os  admits  one  linger. 
(Composition  model ; 


Vaginal  and 
from  a  photo- 


26 


AIDS  IN  OBSTETBIG  TEAGEING. 


tor  in  the  usual  way.  Then,  to  secure  the 
desired  thickness  of  the  composition  model, 
a  la3'er  of  clay  of  the  required  thickness  was 
carefully  placed  in  the  negative  mold,  com- 
pletely and  smoothly  lining  it.  Plaster  is 
now  run  in  over  the  clay  to  form  the  core 
of  the  interior  of  the  mold.  The  plaster 
heing  thoroughly  hard,  the  core  and  nega- 
tive mold  are  separated,  the  clay  removed 
from  the  negative  mold,  both  carefully 
shellacked  upon  their  opposing  surfaces, 
and  when  dry  are  oiled  and  fastened  firmly 
together.  The  mold  is  now  ready  for  the 
reception  of  the  heated  glue  mass. 

Pouring  the  Composition  and  casting  the 
Model. — In  pouring  the  mass  care  should 
be  used  that  it  is  not  too  hot,  otherwise  it  is 
liable  to  stick  to  the  mold  and  core  by 
removing  the  coating  of  shellac  therefrom. 
Moreover,  we  have  found  that  the  higher 
the  temperature  at  which  the  mass  is  poured 
the  greater  will  be  the  subsequent  contrac- 
tion of  the  model  upon  cooling.  At  ordi- 
nary temperatures  the  models  should  not  be 
removed  from  the  molds  for  at  least  six 
hours. 


Fig.  45.— Bimanual  dilatation  of  the  parturient  OS.  Os  admits  two  fingers.  Vaginal  and  supra 
vaginal  portions  of  the  cervix  present.  Commencing  shortening  of  the  cervical  canal. 
(Composition  model  ;  from  a  photograph.) 


I  have  not  found  it  necessary  in  these 
obstetric  models  to  keep  them  when  not  in 
use  in  their  molds  to  avoid  distortion, 
as  Freeborn  *  advised  in  pathological 
models. 

Eemelting  the  Models. — Should  the 
models,  after  continued  use,  shrink  or 
become  hard,  remelting  and  adding  an 
additional  quantity  of  glycerin  to  the 
mass  will  lend  new  flexibility  to  the 
models  and  render  them  less  liable  to 
shrink. 

I  desire  to  express  my  indebtedness 
to  Mr.  James  M.  Kerr,  of  the  firm  of  Kerr 
&  Easario,  sculptors,  229  West  Thirty- 
second  Street,  New  York,  for  valuable 
instruction  and  assistance  in  the  use  of 
plaster  and  composition  for  the  purpose 
indicated  in  this  paper. 

1.  Series  of  composition  models  of 
lower  uterine  segment,  showing  mechan- 
ism of  dilatation,  with  the  gradual  disap- 


FiG.  47.— Bimanual  dilatation  of  the  parturient  OS.    Os  admits  three  fingers.    Suprt 
tion  Of  the  cervix  disappearing.    (Composition  model ;  from  a  photograph.) 


*  Freeborn     A  New  Material  for  Models.    Proceed. 
higs  of  the  New  York  Pathological  Society  for  1891. 


AIDS  IN  OBSTETRIC  TEACEIN&. 


27 


Bimanual  Dilatation  of  the  Parturient 
Os. — Series  Figs.  44  to  50  indicate  our  pre- 
feiTed  method  of  combined  instrumental 
and  bimanual  dilatation  of  the  parturient 
OS.  The  limits  of  the  present  paper  forbid 
my  entering  upon  the  arguments  in  favor  of 
this  particular  variety  of  manual  dilatation, 
which  has  been  given  an  abundant  trial  over 
a  period  of  several  years  in  many  conditions 
of  the  parturient  cervix. 

I  feel  justified,  however,  in  stating  in 
this  place  that  this  method  of  bimanual  dila- 
tation of  the  OS  is  to  be  preferred  to  other 
digital  and  instrumental  methods,  because 
(1)  the  membranes  are  preserved  throughout 
the  operation  or  until  full  dilatation  is  ob- 


FiG.  48. — Bimanual  dilatation  of  the  parturient  OS.    O 
position  of  tlie  hands.    (Composition  model :  fro 


le  half  dilated.    Lateral 
I  photograph.) 


pearance  of  the  supravaginal  portion  of  the  cer- 
vix. 

Figs.  38  to  43  represent  these  composition  cervices, 
and  we  have  added,  to  render  the  illustrations  more 
graphic,  an  outHne  sketch  of  the  upper  vagina  and  cervix 
of  each  to  indicate  the  changes  in  cervical  canal,  external 
and  internal  os,  as  dilatation  progresses. 

The  uses  to  which  such  simple  composition  models 
can  be  put  are  almost  endless,  and  we  have  illustrated 
some  of  these  in  the  following  illustrations: 


a!  dilatation  of  the  parturient  os.  Os  two  thirds  dilated. 
Entire  eUacemcut  of  Internal  os.  (Composition  model ;  from  a  photo- 
graph.^ 


FiQ.  50.— Bimanual  dilatation  of  the  parturient  os.  Os  fully  dilated  and  being 
stretched  to  prevent  accidents  to  the  after-coming  head.  (Composition 
model ;  from  a  photograph.) 


tained;  (3)  there  is  no  interference  with  the  original 
presentation  and  position;  (3)  the  sense  of  touch  of  the 
operator's  fingers  is  unimpaired;  (4)  there  is  no  constric- 
tion of  the  operator's  hands;  (5)  the  amount  of  force  ex- 
erted upon  the  external  ring  can  be  better  estimated, 
and  hence  there  is  less  likelihood  of  lacerations  occur- 
ring. 

Fig.  51  represents  the  position  of  the  fingers  at  the 
ring  of  the  os  in  bimanual  dilatation;  no  encroachment 
into  the  uterine  cavity  occurs. 

Fig.  58  shows  the  position  of  the  hands  as  seen  in 


28 


AIDS  m  OBSTETRIC  TEACHING. 


Fig.  51.— Bimanual  dilatation  of  the  parturient  os,  internal  view,  showing  poei- 
tion  of  the  fingers.  Os  admits  three  fingers  readily.  Internal  08  still  pres- 
ent. No  encroachment  of  the  fingers  upon  the  cavity  of  the  lower  uterine 
segment.    iComposition  model ;  from  a  photograph .) 


an  operation  on  the  living  subject,  and  is  from  a  photo- 
graph taken  at  the  Emergency  Hospital. 

Ordinary  Digital  and  Manual  DiJalaUun  of  the  Par- 
turient Os. — Figs.  53  and  54  represent  the  ordinary  digi- 
tal (with  one  hand)  and  manual  dilatation  of  the  os, 
in  both  of  which  methods  there  is  unnecessary  and 
dangerous  encroaching  on  the  part  of  the  operator's 
hand  upon  the  lower  uterine  segment  and  the  conse- 
quent dangers  of  (1)  displacement  of  presentation  or 
position;  (2)  displacement  of  arms  or  cord;  (3)  prema- 
ture rupture  of  the  membranes,  and  loss  of  the  valuable 
assistance  of  the  liquor  amnii  in  subsequent  manipula- 
tions, as  version,  for  instance;  (4)  premature  separation 
of  a  placenta  prsevia;  and  (5)  constriction  and  loss  of 
sensation  in  the  operating  hand,  and  with  the  consequent 
danger  of  lacerations  of  the  external  ring  from  inability 
to  measure  the  amount  of  force  exerted  and  the  tension 
of  the  ring,  together  with  failure  to  completely  paralyze 
the  ring,  so  that  trouble  in  the  extraction  of  the  after- 
coming  head  results. 


Fig.  52.— Bimanual  dilatation  of  the  parturient  oe.    External  view,  showing  position  of  hands.    (After  a  photograph  of  the  operation  taken  at  the  Emergency 

Hospital.) 


AIDS  IN  OBSTETRIC  TEACHING. 


29 


Fig.  53. — lUustratee  a  common  method  of  manual  dilatation  of  the  parturient  ot> 
and  the  dangers  that  ensne  of  prematurely  rupturing  the  membranes,  dis- 
placing the  presenting  part  or  separating  a  placenta  praevia,  by  reason  of  the 
marked  encroachment  of  the  fingers  of  the  operator  into  the  cavity  of  the 
lower  uterine  segment.    (Composition  model  :  from  a  photograph.) 


Fig.  54.— Dluetrates  a  common  method  of  single-handed  manual  dilatation  of 
the  parturient  os,  which  has  the  same  objections  as  the  method  depicted  in 
Fig.  53,  but  to  a  less  degree.    (Composition  model ;  from  a  photograph.) 


f3.  .')7.— Dangers  of  breech  extraction  through 
Same  as  Fig,  r>f).  Seen  from  the  uterine  cavity, 
a  photograph.) 


an   imperfectly  dilated  os. 
(Composition  model ;  froqi 


gh  an  imperfectly  dilated  os.  Ex- 
the  legs  causes  extension  of  the 
ina.    (From  a  photograph  ;  corn- 


Fig.  55  shows  the  interior  of  the  lower  uterine  seg- 
ment, with  an  os  the  size  of  two  fingers,  a  Barnes's 
cervical  dilator  in  position,  and  the  dangerous  encroach- 
ment of  the  latter  into  the  cavity  of  the  uterus,  render- 
ing malpresentation  liable  to  occur. 

Dangers  of  Breech  Extraction  through  an  Imperfectly 
Dilated  Os. — Figs.  56  and  57  illustrate  this  condition, 
selected  from  many  other  equally  important  ones. 

When  the  student  is  made  to  see  what  may  happen 


30 


AIDS  IN  OBSTETRIC  TEAOHINa. 


Flo.  58.— Cervix  partially  dilated.     Membranes  ruptured.    Vertex  presenting. 
Prolapse  of  hand  and  cord.    (Composition  model  ;  from  a  photograph.) 


should  lie  thoughtlessl}'  make  traction  upon  a  leg- 
in  breecli  presentation  before  the  completion  of  the 
first  stage  of  labor,  he  is  not  likely  to  forget  the  dan- 
gers of  such  manipulutions  in  the  extended  head  and 
arms  and  the  resulting  impaction  and  death  of  the 
foetus. 

Fig.  58  represents  prolapse  of  the  cord  and  hand  in 


Fig.  59. — Cervix  partially  dilated.  Labor  obstructed  by  reason  of  partial  exten- 
sion of  the  head,  causing  occipito-frontal  diameter  to  pass  through  cervix 
and  pelvis.    (Composition  model ;  from  a'photograph.) 

the  middle  of  the  first  stage,  and  its  accompanying  dan- 
gers to  the  foetus;  and  Fig.  59  illustrates  a  common  cause 
of  obstructed  labor  due  to  an  imperfect  attitude  of  the 
fcetus.  The  chin  has  left  the  sternum,  resulting  in  in- 
complete flexion  of  the  head  and  the  passage  of  a  larger 
diameter  than  necessary  (occipito-frontal)  through  the 
.cervix  and  pelvis. 


The  following  twenty-four  groups  of  illustration's  are  from  photographs  of  copper-plated  plaster  models. 
GROUP   I.— NORMAL   PELVIS.     MALE   TYPE. 

{'^  natural  size.) 


LUMBO-SACRO-COCCYGEAL   CURVE.-INCLINATION    AND 
SHAPE  OF   SYMPHYSIS.-PUBIC  ARCH   AND   ANGLE. 


" 

" 

ri? 

rri 

CIRCUMFERENCE. 

24 

61 

TRANSVERSE  OF  INLET, 

S 

IC^ 

TROCHANTERS, 

(25, 

32 

RIGHT  OBLIQUE    INLET, 

4^ 

12. 

Spines, 

?'if 

25 

LEFT  OBLIQUE   INLET, 

4 

12 

Crests, 

ID?, 

Sfl 

RIGHT  PELVIC  WALL. 

4^ 

II 

External  Conjugate, 

bh 

16 

leftpIlvVcvi^all 

4^ 

IL 

m 

RIGHT  EXTERNAL  OBUOUE, 

&k 

21 

POST?RroH"'pELVIC  WALL 

4^ 

LEFT  EXTERNAL  OBLIQUE 

S'4 

2.1 

SACRO-COCCVGEAL  CURVE 

5:5t 

Height  of  Sympliysis, 

I's 

5 

TRANSVERSE  OUTLET. 

3^ 

<=> 

DIAGONAL  CONJUGATE 

12 

"SJTL"E°T';?oJi;i?E''AL., 

5/4 

&i 

ANATOMICAL  CONJUGATE, 

5fi 

10 

''S^TL°i''ittll1'S'' 

4| 

II 

Obstetric  Conjugate, 

3/s 

9 

CURVE  OF  SACRUM, 

^ODERATcl 

GROUP   IL— NORMAL   PELVIS.     FEMALE   TYPE. 

i  natural  size.) 


J 


LUMBO-SACRO-COCCYGEAL   CURVE.— INCLINATION    AND 
SHAPE   OF   SYMPHYSIS.-PUBIC  ARCH   AND   ANGLE, 


" 

~ 

rr 

fSl 

CIRCUMFERENCE, 

25V 

S9 

TRANSVERSE  OF  INLET, 

s 

12V 

TROCHANTERS, 

Hi 

29 

RIGHT  OBLIQUE   INLET, 

s 

12V 

Spines, 

9^4 

a5 

LEFT  OBLIQUE  INLET, 

J 

12', 

Crests, 

II 

26 

rightp'e°lv7c  wall. 

4*4 

II 

External  Conjugate, 

r 

IS 

LEFT  PeLvTc  WALL, 

ik 

II 

RIGHT  EXTERNAL  OBLIQUE, 

S'4 

21 

po5T?riSS''pelvic  wall. 

4V 

ll>. 

LEFT  EXTERNAL  OBLIQUE 

S'+ 

21 

SACRO-COCCVGEAL  CURVE 

ji' 

(2'.2 

Height  of  Symphysis, 

1^.. 

4'.: 

transverse  OUTLET. 

4 

10 

DIAGONAL  CONJUGATE, 

+  c 

II 'i 

''SuTl\°t';?oJcVG°e''al,, 

.H 

.9V 

ANATOMICAL  CONJUGATE. 

4 

10 

"Sutle°t'™?Jral°," 

S 

l2Jr 

Obstetric  Conjugate, 

5,-? 

10 

CURVE  of  SACRUM, 

MODERHrE  1 

r- 

^ 

PUBIC  ANGLE 

es 

u 

GROUP   Til.— I'ELVIS   DEFORMED   BY   CONGENITAL  DISLOCATION    OF   BOTH    FEMURS. 
CHILD   TEN  YEARS   OLD. 


I}{  naluval  size.) 


^ 

^T 

T!? 

" 

CIRCUMFERENCE, 

lt.5r 

4-Z 

-■4 

I 

TROCHflNTEHS, 

^'4 

t\ 

RIGHT  OBLIQUE  INLET, 

c 

ic 

Spines, 

6% 

11 

LEFT  OBLIQUE   INLET, 

c-v 

<.  . 

Crests, 

6> 

n 

right"'p'e\vIc  wall. 

5 

T'c 

External  Conjugate, 

4.I1 

He 

^j,^IJ|[=7j^,5LL, 

<u 

I 

RIGHT  EXTERNAL  OBUOUE. 

•?' I: 

14 

post"eriSS''pelvic  wall. 

P 

t^c 

LEFT  EXTERNAL  OBLIQUE 

s* 

15!' 

SACRO-COCCYGEAL  CURVE 

4- 

10 

Height  Of  Symphysis. 

l?ii 

3'-, 

TRANSVERSE  OUTLET. 

0^ 

c 

DIAGONAL  CONJUGATE, 

3^-t 

P'.2 

^Z's 

,?« 

ANATOMICAL  CONJUGATE 

5'« 

s 

*SJ^['^t™aJral°" 

2-4IT  1 

Obstetric  Conjugate, 

3 

'  ■; 

CURVE  OF  SACRUM, 

MOPERATeI 

3 

^, 

PUBIC  ANGLE 

?6^  1 

GROUP   IV.— PELVIS   DEFORMED   BY   EXTREME   DEGREE   OF   OSTEOMALACIA. 
(DUPUYTBEN   MUSEUM.) 

(}£  natural  size.) 


" 

^T 

" 

fur 

C.PCUMFERENCE, 

24; 

ti:.. 

TRANSVERSE   OF   INLET. 

4* 

II 

TROCHANTERS. 

"'f 

41^ 

RIGHT  OBLIQUE    INLET, 

4+ 

II 

Spines, 

t'c 

I'' 

LEFT  OBLIQUE  INLET 

4+ 

II 

Crests, 

&t 

fli' 

RIGHT  PE°Lvlc  WALL, 

f 

10 

External  Conjugate. 

sv 

•II 

^^„'il'S',Iv,„LL. 

4- 

10 

RIGHT  EXTERNAL  OBLIQUE, 

&'• 

-''t 

POSTERIOR  PELVIC  WALL, 

"~i 

te 

LEFT  EXTERNAL  OBLIQUE 

sv 

ii 

SACRO-COCCYGEAL  CURVE 

S'^ 

15!: 

Height  Of  Symphysis, 

r> 

;> 

TRANSVERSE   OUTLET. 

'ii 

7 

DIAGONAL  CONJUGATE 

5i 

14 

"Sutle°t'^?Ic"g°e"al.. 

4- 

10 

ANATOMIC.L  CONJUGATE 

j" 

l£'- 

"SiT^Ei'Mll^l'L," 

J+ 

15^ 

Obstetric  Conjugate, 

+'+ 

I'l 

CURVE  OF  SACRUM. 

INKEAStD  1 

^,^ 

4^4-"! 

GROUP   v.— PELVIS   DEFORMED   BY   CONGENITAL  DISLOCATION   OF   BOTH    FEMURS. 

(3-^  natural  size.) 


" 

" 

P? 

p^ 

CIRCUMFERENCE, 

r-f? 

62 

TRANSVERSE  OF  ,NLET, 

1^''' 

14 

TROCHANTERS. 

15  !f 

m 

RIGHT  OBLIQUE    INLET, 

ir^ 

Spines, 

10^ 

2t,i 

LEFT   OBLIQUE   INLET, 

,-r 

i?V 

Crests, 

(1 

28 

RIGHT  p'e°LvIc  wall. 

4 

10 

External  Conjugate, 

Y 

IS 

leftpH.vIJwall, 

4 

10 

RICHT  EXTERNAL  OBUQUE. 

S4 

"<•> 

posteriSr'pelvio  wall. 

5' 

\Vi 

LEFT  EXTERNAL  OBUQUE 

8-; 

^••7 

sacro-coccygeal  curve 

^"'^ 

15 

Height  of  Symphysis, 

"'"+ 

fc" 

transverse  outlet. 

ir% 

13!? 

DIACONAL  CONJUGATE. 

?? 

15 

"Su"e°t'^??Jc;g°e''al,. 

y^ 

<^ 

ANATOMIC.L  CONJUGATE. 

5 

I2'd 

''SiTL°T'',ircll'8'" 

4* 

11'? 

Olistetrio  Conjugate, 

4i 

II 

curve  OF  SACRUM. 

fLATTENEOI 

r 

^^ 

PUBIC  ANGLE 

115"  1 

GROUP  VI.— RHACHITIC  PELVIS  WITH   ENLARGEMENT  OF  THE   BONES.     ADULT   EIGHTEEN 
YEARS   OLD.     (DUPUYTREN   MUSEUM.) 

(X  n.itural  size.) 


™ 

" 

" 

" 

CIRCUMFERENCE 

%\ 

S}'i 

TRANSVERSE  OF  INLET. 

-^V 

II 

TROCHANTERS. 

II 

'ZS 

RIGHT  OBLIQUE  INLET. 

4V 

K'f 

Spines, 

I0^^ 

LT^ 

LEFT  OBLIQUE  INLET. 

4V 

It 

Crests, 

]&'". 

2t^ 

RIGHT  PE^LvIc  WALL. 

5^^ 

9 

External  Conjugate, 

f'^ 

Wi 

LEFT  pR^VJ  WALL, 

>'S 

9 

RIGHT  EXTERNAL  OBLIQUE. 

? 

CW 

POST^r'iSS^PELVIC  wall. 

"^-9 

10 

'20 

SACRO-CoSgEAL  CURVE 

$ 

I'-i 

Height  Of  Symphysis, 

I'-f 

4'? 

TRANSVERSE  OUTLET, 

4 

10 

DIAGONAL  CONJUGATE. 

'A 

9 

"SuTrE°T'^CTCcyl?E''AL>, 

?v 

i^'c 

ANATOMICAL  CONJUGATE. 

5 

Xi 

"SutlTt'IaJrau" 

4 

10 

Obstetric  Conjugate, 

'""» 

ik 

CURVE  OF  SACRUM, 

INCRtAftD  1 

(. 

115"  1 

GROUP  VII.— RIIACIilTIC  PELVIS  WITH  SLIGHT  CONTRACTION  OF  THE  PELVIC  INLET  AND 
MARKED  CONTRACTION  OF  OUTLET.  LATERAL  DEVIATION  OF  THE  PROMONTORY  TO 
THE   LEFT.     ADULT.     (DUPUYTREN   MUSEUM.) 

(3^  natural  i 


T? 

TT 

" 

" 

CIRCUMFERENCE. 

V 

^yn 

TRANSVERSE  OF  INLET. 

4 

10 

TROCHANTERS, 

n 

oo 

RIGHT  OBLIQUE    INLET 

4- 

10 

Spines, 

?> 

'iOk 

LEFT  OBLIQUE   INLET 

4 

10 

Crests, 

e 

1? 

RIGHT  PeIvIc  wall. 

"I'ii 

? 

External  Conjugate. 

T 

18 

LEFT  pfl.v'i'J  WALL, 

j'i 

^ 

RIGHT  EXTERNAL  OBLIOUE, 

l^ 

1? 

post?r'iSS^pelvic  wall. 

n 

6 

LEFT  EXTERNAL  OBLIQUE 

li^ 

SACBO-COCCYGEAL  CURVE 

-/-if 

II 

Height  of  Symphysis. 

I's 

■i 

TRANSVERSE    OUTLET 

2'. 

6 'a 

DIAGONAL  CONJUGATE. 

■+y 

\0k 

j> 

n 

ANATOMICAL  CONJUGATE. 

n 

\t 

''SiTL°T'':tll«"S'' 

-f 

10 

Obstetric  Conjugate, 

-4- 

10 

CURVE  OF  SACRUM. 

mmn  1 

7 

^ 

PUBIC  ANGLE 

2t"| 

GROUP  VIII.— DEFORMED  PELVIS  WITH  CONTRACTION  OF  THE   PELVIC   INLET  AND  WIDENING 
OF   THE   PELVIC   OUTLET.     ADULT.     FALSE   PROMONTORY.     (DUPUYTREN   MUSEUM.) 

{}£  natural  size.) 


" 

" 

T? 

" 

C.RCUMFERENCE. 

er, 

SJi 

TRANSVERSE  OF  INLET. 

;> 

m 

TROCHANTERS. 

II 

2{? 

RIGHT  OBLIQUE   INLET, 

4h 

\\k 

Spines, 

ou 

24 

LEFT  OBLIQUE   INLET 

-f'-f 

If 

Crests, 

lov 

26 

RIGHT  PE°Lvlc  WALL. 

-f 

(0 

External  Conjugate. 

bi 

16 

LEFT'JimJwALL. 

?l 

?^ 

RIGHT  EXTERNAL  OBLIQUE. 

8 

20£ 

postehiSr'pelvic  wall. 

4'? 

II 

8 

20; 

SACRO-GOCCYGEAL  CURVE 

4*i 

\j<i 

Height  Of  Symphysis. 

I'e 

4 

TRANSVERSE  CUTLET. 

^ 

iVi 

DIAGONAL  CONJUGATE. 

4 

10 

''SJ"e°t'^?oJcyg°e''al.. 

51: 

14 

ANATOMIC.L  CONJUGATE. 

j'i 

9 

"SjTrE°Tli!JRAU.'' 

ik 

(3V 

Obstetric  Conjugate, 

i>^ 

S't 

CURVE  OF  SACRUM. 

fiATTENeo  1 

« 

PUBIC  ANGLE 

IIS'I 

GROUP   IX.-DEFORMED   PELVIS.     DRIVING   IN  OF  THE   ILIUMS.     CORDIFORM   SHAPE   OP 
THE   PELVIC   INLET.     FALSE   PROMONTOPvY. 

iX  natural  size.) 


TT 

■S" 

u!? 

rinj 

CIRCUMFERENCE, 

18  W6 

TRANSVERSE  OF  INLET, 

fl^ 

111 

TROCHANTERS. 

6;-* 

IX 

RIGHT  OBLIQUE   INLET, 

4 

w 

Spines, 

C) 

11 

LEFT  OBLIQUE  INLET, 

i± 

11 

Crests, 

V-4 

m        R.GHri'ErvlcW,LL. 

jV 

M 

External  Conjugate, 

4- 

10 

leftpIlviJwall, 

>'^ 

nv 

RIGHT  EXTERNAL  OBLIQUE. 

&\ 

IT 

P05TERlSST.ELVIC  WALL 

-/'fl 

II 

LEFT  EXTERNAL  OBLIQUE 

^h 

ilk 

SACRO-COCc'iGEAL  CURVE 

r> 

|?V 

Height  Of  Symphysis, 

\'i 

5 

TRANSVERSE   OUTLET. 

5 

i?i 

DIAGONAL  CONJUGATE 

5  V 

S? 

°o;TrE°T';?oJc?!?E''AL,, 

0 

5 

ANATOMIC.L  CONJUGATE. 

i's 

S'l 

*SJTrE°T™AjRAu" 

0 

.5' 

OI)stetric  Conjugate, 

}H 

-h 

CURVE  OF  SACRUM. 

FLATTENED  1 

lt?\ 

GROUP  X.-RHACIIITIC  PELVIS.  JUTTING  FORWARD  OF  THE  SACRUM.  SHORTENING  OF 
THE  ANTERO-POSTERIOR  DIAMETERS  OF  THE  TRUE  PELVIS.  FALSE  PROMONTORY 
(DUPUYTREN   MUSEUM.) 


(}{  natur.il  size.) 


" 

^ 

Tns" 

n 

CIRCUMFERENCE. 

?0^ 

^"•f 

TRANSVERSE  OF  INLET. 

IV 

Hi 

TROCHANTERS. 

10 

i^s 

RIGHT  OBLrQUE  INLET, 

i^ 

llii 

Spines, 

QU 

2-f 

LEFT  OBLIQUE  INLET, 

-\'i 

II 

Crests, 

h 

C)C) 

RIGHT  PE°Lvlc  WALL, 

^ 

5. 

External  Conjugate, 

p^rt 

15k 

LEFT  piLVK  WALL, 

3V 

»-"> 

RIGHT  EXTERNAL  OBLIQUE. 

("'+ 

m 

POSTERIOR  PELVIC  WALL. 

4V 

II 

LEFT  EXTERNAL  OBLIQUE 

("V 

\v% 

^ACRO-COCc'^VGEAL  CURVE 

5^ 

li2i 

Height  of  Symphysis. 

['? 

4 

TRANSVERSE  OUTLET. 

,"^i 

.^ 

DIAGONAL  CONJUGATE, 

?i 

9 

ANFERO-POSTERIOR 

^ 

X 

ANATOMICAL  CONJUGATE. 

^ 

T? 

''ojTrE°T'^iACRAu" 

>^ 

2i 

EWfP 

Obstetric  Conjugate, 

V^ 

T 

CURVE  OF  SACRUM, 

FIMT 

! 

Wi 

=3- 

GROUP  XL— KHACIIITIC  PELVIS.  JUTTING  FORWARD  OF  THE  SACRAL  PROMONTORY. 
ANTERO-POSTERIOR  FLATTENING  OF  THE  INLET.  LATERAL  FLATTENING  OF  THE 
OUTLET.     CORDIFORM   SHAPE  OF   THE   PELVIC   INLET.     ADULT.     FALSE   PROMONTORY. 

.    {}{  natural  i 


" 

" 

" 

" 

CIBCUMFERENCE, 

\?\ 

^Q 

TRANSVERSE  OF  INLET, 

5 

12 'i 

TROCHANTERS. 

m 

m 

RIGHT  OBLIQUE  INLET, 

4 

10 

Spines, 

(O'-f 

tVi 

LEFT  OBLIQUE  INLET 

4fi- 

II 

Crests, 

lOV 

£5 

RIGHT  p'e°LvIc  wall. 

-?^ 

9 

External  Conjugate, 

J 

liH 

LEFT  PELVIC  wall, 

?'? 

? 

RIGHT  EXTERNAL  OBLIQUE, 

TV 

(^? 

poster'iSS^pelvic  wall. 

r-* 

IS 

LEFT  EXTERNAL  OBLIQUE 

T's 

19 

SACRO.COCCYGE.L  CURVE 

p 

If? 

Height  of  Symphysis, 

1'? 

T  *'' 

TRANSVERSE  OUTLET, 

5'# 

9 

DIAGONAL  CONJUGATE. 

5V 

8'f 

''S;tl"e°t';??J"ge'"ali, 

4 

10 

ANATOMICAL  CONJUGATE. 

2'!^ 

p'" 

"SutlTt'^sIJr^'S." 

5^? 

f) 

Obstetric  Conjugate, 

o 

? 

CURVE  OF  SACRUM, 

FUTTENEdI 

.. 

PUBIC  ANGLt 

SX"  1 

GROUP  XII.— RHACHITIC  PELVIS.  LATERAL  DEVIATION  OF  THE  SACRUM  TO  THE  LEFT. 
SINKING  IN  OF  THE  ILIUM  OF  THE  CORRESPONDING  SIDE.  SHORTENING  OF  THE 
RIGHT  OBLIQUE  DIAMETER  OF  THE  PELVIC  INLET.  ADULT.  FALSE  PROMONTORY. 
(DUPUYTREN   MUSEUM.) 


{}£  natural 


" 

T!r 

T? 

" 

CIRCUMFERENCE. 

20 

p| 

TRANSVERSE  OF  INLET, 

4'-f 

12 

TROCHANTERS. 

10!. 

^6 

RIGHT  OBLIQUE    INLET, 

?'« 

C) 

Spines, 

9'f 

??'•> 

4V 

II 

Crests, 

f;- 

li' 

RIGHT  PE°Lvlc  WALL, 

^V 

?'i 

External  Conjugate, 

G 

15 

LEFT  plmJ  WALL, 

^ 

Vi 

RIGHT  EXTERNAL  OBLIQUE. 

v'V 

m 

POST?RlSS^PELV,C  WALL, 

■f's 

\n 

LEFT  EXTERNAL  OBLIQUE 

$ 

?(i{ 

SACRO-COCCVGEAL  CURVE 

?'f 

m 

Height  Of  Symphysis. 

\h 

-f'-i 

TRANSVERSE  OUTLET, 

p'? 

(4 

DIAGONAL  CONJUGATE, 

-fV 

U 

''SuTlZT''°olc"cAi.\ 

T 

Vi 

ANATOMICAL  CONJUGATE, 

j's 

^ 

''Si"°j'%rc%i'S'' 

i's 

lOV 

Obstetric  Conjugate, 

J} 

TV 

CURVE  OF  SACRUM, 

fLATTENEO  1 

n 

'15'  1 

GROUP    XT  IT.— OVAL    OBLIQUE   PELVTS    OF    NAEGELE. 

(}{  natural  size.) 


" 

TT 

™ 

TUT 

CIRCUMFERENCE. 

^> 

SVi       X—RSE  OF  INLET, 

4'-^ 

(1 

TROCHANTERS. 

loV 

5<.J 

RIGHT  OBLIQUE  INLET, 

yf 

8 

Spines, 

f^^c 

OO. 

LEFT  OBLIQUE  INLET, 

p 

fe'f 

Crests, 

iO 

2.T^ 

RIGHT  I'eIvIc  wall. 

4'j 

ii'i 

External  Conjugate, , 

r'c 

19 

^^r-r"l'Lv"I  WALL, 

+'4 

(1 

RIGHT  EXTERNAL  OBLIQUE. 

G'i 

IT 

POSTERlSS^PELVIC  WALL, 

4's 

II 

LEFT  EXTERNAL  OBLIOUE, 

rv 

\fi 

SACRO-COCC™  EAL  CURVE 

5"'-* 

I5'2 

Height  of  Symphysis, 

r-- 

TRANSVERSE  OUTLET, 

? 

T'2 

DIAGONAL  CONJUGATE, 

4'f 

ii 

"™"E°T';?IJiYi?E''AL,, 

-^'f 

II 

ANATOMICAL  CONJUGATE. 

r^ 

11'^ 

''SJtl"e°t'!?aJrTl°,'' 

+'^ 

(£ 

Obstetric  Conjugate, 

i'i 

m 

CURVE  OF  SACRUM, 

flATTENtCl 

,. 

PUBIC  ANGLE 

iU 

GROUP   XIV.— DEFORMED    PELVIS   WITH    CONSIDERABLE    SHORTENING    OF   THE    TRANSVERSE 
DIAMETER.     JUTTING   FORWARD   OF  THE   SACRAL  PROMONTORY.     FALSE  PROMONTORY. 

(}£  natural  size.) 


" 

" 

" 

TT 

CIRCUMFERENCE, 

(J^^4 

-fr^ 

TRANSVERSE  OF  INLET, 

yi 

^ 

TROCHANTERS. 

?''f 

?4 

RIGHT  OBLIQUE  INLET, 

?''2 

? 

Spines, 

r'« 

^0 

LEFT  OBLIQUE  INLET, 

y-i 

9 

Crests, 

8'-* 

o»-> 

RIGHT  PE^LvIc  WALL. 

4 

10 

External  Conjugate, 

6V 

I6'j 

LEFT  pIIvVc  WALL. 

4 

10 

RIGHT  EXTERNAL  OBLIQUE. 

r? 

18 

POSTERIOR  PELVIC  WALL. 

fs 

m 

LEFT  EXTERNAL  OBLIQUE 

T'lf 

18 

SACRO-COCCYGEAL  CURVE 

4'-* 

1^ 

Height  of  Symphysis, 

Kif 

4 

TRANSVERSE  OUTLET. 

\"4 

4'^ 

DIAGONAL  CONJUGATE. 

4 

10 

ANTEflO-POSTEHIOR 

5'i 

1? 

ANATOMICAL  CONJUGATE. 

y? 

|0 

*SufL\°T'^?AjRAL°,'' 

yi 

14 

Obstetric  Conjugate, 

yi 

5 

CURVE  OF  SACRUM, 

FlATTENEol 

It 

^ 

PUBIC  ANCLE 

5X'l 

GROUP   XV.— PELVIS   DEFORMED   BY   CONGENITAL   DISLOCATION   OF   ONE   FEMUR. 

(3^  natural  size.) 


" 

TT 

" 

fir 

CIRCUMFERENCE, 

S-f'f 

(52 

TRANSVERSE  OF  INLET, 

^ 

iVi 

TROCHANTERS. 

12 

pOi 

RIGHT  OBLiaUE  INLET, 

i?'i 

14 

Spines, 

iO 

??i 

-f!i 

il'i 

Crests, 

9'-f 

2p 

RIGHT  IkTlIc  WALL. 

4 

10 

External  Conjugate, 

T^ 

1$ 

LEFT  PELVIC  WALL, 

,? 

X'% 

RIGHT  EXTERNAL  OBLIQUE, 

^'<? 

2?^ 

POSTERIOR  PELVIC  WALL. 

j'i 

9 

LEFT  EXTERNAL  OBUaUE, 

f^V 

in 

SACRO-clcCYGEAL  CURVE 

^  (2^1 

Height  of  Symphysis, 

r-* 

fa 

TRANSVERSE  OUTLET. 

^ 

l^isJ 

DIAGONAL  CONJUGATE. 

?'" 

l?'2 

's;"e°t™oJ"l°e''al.. 

4 

ipI 

ANATOMICAL  CONJUGATE. 

rs 

|2 

OUTLET  (SACRALl. 

r* 

I.V^I 

Obstetric  Conjugate, 

n 

II 

CURVE  OF  SACRUM. 

IKCBMJEO  1 

,r 

PUBIC  ANGLE 

114"  1 

GROUP   XVI.— RHACHITIC    PELVIS.     CHILD. 

(^  natural  size.) 


" 

" 

" 

" 

CIRCUMFERENCE. 

14 

??^ 

TRANSVERSE  OF  INLET, 

2'ii 

?'" 

TROCHANTERS. 

<^'4 

n 

RIGHT  OBLIQUE   INLET 

e^rt 

6 

Spines, 

T'l? 

iH 

LEFT  OBLIQUE  INLET. 

27' 

6 

Crests, 

(r>'i 

ir 

RIGHT  PE°LvIc  WALL. 

^ 

i's 

External  Conjugate, 

o-f 

p^ 

LEFT  pIl^vVJ  WALL. 

5 

n 

RIGHT  EXTERNAL  OBLIQUE, 

j-Tt 

14 

POSTERlSS"'pELVIC  WALL. 

o 

^ 

LEFT  EXTERNAL  OBLIQUE 

?'^ 

ife 

S.CRO-COCc'VgEAL  CURVE 

^ 

te 

Height  of  Symphysis, 

IV 

i''^ 

TRANSVERSE  OUTLET 

l'+ 

^ 

DIAGONAL  CONJUGATE. 

<^'.7 

fk- 

OUTLET  iCOCCYGEAL). 

l'2 

4 

ANATOMICAL  CONJUGATE. 

r+ 

4V 

''Si;TrE°T';iAjRA'L°'' 

2'!? 

?^' 

Obstetric  Conjugate, 

l'2 

4 

CURVE  OF  SACRUM. 

INCMA^tD    1 

vV. 

65^1 

GROUP  XVIL— PELVIS    DEFORMED  BY  SPONTANEOUS   DISLOCATION  OF  THE  LEFT   FEMUR. 

(3^  natural  size.) 


" 

" 

T? 

" 

CJRCUMFERENCE, 

?4 

C^i 

TRANSVERSE  OF  INLET, 

p 

\i\ 

TROCHANTER  S. 

II V 

pO 

RIGHT  OBLIQUE  INLET, 

i"*' 

/?•? 

Spines, 

f>'4 

V 

LEFT  OBLIQUE  INLET, 

-f'e 

i(v 

Orests, 

\0'i 

26 

RIGHT  PE°Lvlc  WALL. 

-fl 

(? 

External  Conjugate, 

62 

1^ 

■f? 

II '« 

RIGHT  EXTERNAL  OBLIQUE, 

n 

21%      post-eISK^elvicwall. 

y^ 

p;: 

LEFT  EXTERNAL  OBLIQUE, 

f^v 

m 

SACRO-COCC™  EAL  CURVE 

?'i 

If 

Height  of  Symphysis, 

I's 

O'i 

TRANSVERSE  OUTLET, 

5'-* 

IfV 

DIAGONAL  CONJUGATE. 

r? 

\Vi 

";"e°t';?ij"gTal,, 

?(?r'f| 

ANATOMICAL  CONJUGATE. 

n 

11% 

*SjTLE°-f';iljRAU." 

4'^ 

II 

Obstetric  Conjugate, 

n 

[(i'i 

CURVE  OF  SACRUM, 

incRu^td  1 

•n 

^ 

PUBIC  ANGLE 

iir| 

GROUP   XVIII.— PELVIS   DEFORMED   BY   OSTEOMALACIA.     SLIGHT   DEGREE.     ADULT. 
(DUPUYTREN   MUSEUM.) 

[yi  natural  size.) 


T!? 

" 

" 

" 

CIRCUMFERENCE. 

??5 

;>;^ 

TRANSVERSE  OF  INLET, 

/v 

|4 

TROCHANTERS. 

(O'-f 

?rf' 

RIGHT  OBLIQUE    INLET, 

(% 

Spines, 

P> 

?5 

LEFT  OBLIQUE   INLET 

-fV 

\1'i 

Orests, 

10'-' 

?T4 

RIGHT  PE^LvIc  V»ALL. 

4'?- 

\% 

Etternal  Conjugate, 

rv 

li?? 

LEFT?il.°i<5"wALL, 

f? 

\% 

RIGHT  EXTERNAL  OBLIQUE. 

8f 

J'l 

pobteriSrT.elvic  wall. 

r^ 

LEFT  EXTERNAL  OBLIQUE 

fV^ 

'?! 

SACBO-COCC^VGEAL  CURVE 

i? 

l?V 

Height  Of  Symphysis, 

r-f 

■+? 

TRANSVERSE   OUTLET, 

^^^ 

P 

DIAGONAL  CONJUGATE. 

■f^rf 

1^: 

"^^'"^"T^JJiYGT.L., 

.?'" 

0, 

ANATOMICAL  CONJUGATE, 

\H 

II 

''alMi^''°^VcK^°" 

-f'/5 

w 

Obstetric  Conjugate, 

4 

10 

CURVE  OF  SACRUM, 

INlRUfED  1 

£j 

GROUP   XIX.— DEFORMED   PELVIS.     FUNNEL-SHAPED   ENLARGEMENT   OF  THE   PELVIC   INLET. 
CONTRACTrON    OF   PELVIC   OUTLET.     (DUPUYTREN   MUSEUM.) 

(H  natural  «izc.)  ^ 


" 

TT 

T!? 

fir 

CIRCUMFERENCE. 

ftvi 

$S 

TRANSVERSE  OF  INLET, 

?'¥ 

1? 

TROCHANTERS. 

(?  + 

?'\ 

RIGHT  OBLiaUE   INLET. 

^'-f 

1^ 

Spines, 

m 

u- 

LEFT  OBLIQUE   INLET. 

■><^ 

1+ 

Crests, 

m 

?rf 

RIGHT  I'eIvTc  wall. 

?'4 

f?^i 

External  Conjugate, 

n? 

r?o 

5^ 

9^ 

RIGHT  EXTERNAL  OBLIQUE. 

S'-f 

0(^ 

POSTERlSS'^PELVIC  WALL. 

f'*' 

1+ 

LEFT  EXTERNAL  OBLIOUE, 

,9 

?^ 

SACR0-C0CC™GE.L  CURVE 

T'-f 

1?^ 

Height  of  Sympliysis, 

? 

,-> 

TRANSVERSE  OUTLET. 

4 

(0 

DIAGONAL  CONJUCATE. 

b 

K'^ 

'™TrE°T':??JcYG°E''ALi. 

S# 

r 

ANATOMICAL  CONJUGATE, 

?^ 

K 

»^J^['°.^';gSTER,OR 

4^ 

II 

Obstetric  Conjugate, 

^* 

l?V 

CURVE  OF  SACRUM, 

MODERATE  1 

>1 

s^i 

GROUP   XX.-RHACHITIC   PELVIS.     OBSTETRIC   CONJUGATE   OF   THE   PELVIC   INLET,   FOUR 
CENTIMETRES.     FALSE   PROMONTORY.     CESAREAN   SECTION   PERFORMED. 


{}{  natural  size.) 


■™ 

TIT 

" 

" 

CIRCUMFERENCE. 

CO 

?l 

TRANSVERSE  OF  INLET. 

4i- 

ui 

TROCHANTERS. 

10-^ 

?T^ 

RIGHT  OBLIQUE   INLET. 

4 

10 

Spines, 

f> 

^?? 

LEFT  OBLIQUE  INLET, 

?'s 

? 

Crests, 

!^-^ 

OOI, 

RIGHT  I'e°LvIc  wall. 

rs 

External  Conjugate, 

\ik 

LEFT  pIlvVJ  WALL 

::v 

Ill 

RIGHT  EXTERNAUOBLIQUE. 

t7?f 

IT 

post'^eriSS'pelvic  wall. 

? - 

?> 

LEFT  EXTERNAL  OBLIQUE. 

Tt* 

U'^ 

SACRO-COCCYGEAL  CURVE 

^'i 

1?? 

Heiglit  of  Sympiiysis. 

!"-» 

+'e 

TRANSVERSE  OUTLET, 

AU 

II 

DIAGONAL  CONJUGATE, 

^J 

(? 

"SiItl"e°t';?SJ"gTali, 

£>J 

ANATOMICAL  CONJUGATE, 

Ti? 

r 

*SJ"e°t';?aJra",'' 

4'?- 

m 

Obstetric  Conjugate, 

Ki 

•+ 

CURVE  OF  SACRUM, 

FUTTENEHl 

ao 

PUBIC  ANGLE 

"""I 

GROUP  XXI.— RIIACIHTIC   PELVIS.     OBSTETRIC  CONJUGATE,   FOUR  CENTIMETRES   AND  A   HALF 

CJi;SAREAN   SECTION   PERFORMED. 

(J^  natural  size.) 


" 

™ 

" 

fll^ 

CIRCUMFERENCE. 

?(n 

52 

TRANSVERSE  OF  INLET. 

2?^ 

-}-| 

TROCHANTERS. 

m 

ocf 

RIGHT  OBLIQUE   INLET, 

5ff 

9  1 

Spines, 

s'-* 

no 

LEFT  OBLIQUE  INLET, 

,Vf^B'2| 

Crests, 

ip'i 

26 

RIGHT  PE°Lvlc  WALL. 

?> 

T>f 

External  Conjugate. 

i^^i 

16 

leftpILviJwall, 

5^ 

,S 

RIGHT  EXTERNAL  OBLIQUE, 

CA 

IT 

POSTER1SST.ELVIC  WALL. 

e-^ 

5^ 

LEFT  EXTERNAL  OBLIOUE 

X'i 

le 

S.CRO-COCCVGEAL  CURVE 

?>+ 

|5^ 

Height  of  Symphysis. 

2^4 

T 

TRANSVERSE   OUTLET. 

V^ 

T 

DIAGONAL  CONJUGATE. 

^'^ 

*Si;T!'E°T'^SIJcyGT.L. 

V-> 

T 

ANATOMICAL  CONJUGATE. 

^ 

7's 

"™TrE°T'^i«jRA'L°'' 

45 

(2 

Obstetric  Conjugate. 

\H 

n 

CURVE  OF  SACRUM, 

IKtREA'jEO  1 

■\.\ 

45^1 

GROUP   XXIL— RHACniTIC   PELVIS.     OBSTETRIC   CONJUGATE,    FOUR   CENTIMETRES. 
FALSE   PROMONTORIES.     CESAREAN   SECTION   PERFORMED. 

(}4  natural  size.) 


" 

■J" 

n?" 

f^n 

iO 

,^' 

TRANSVERSE  OF  INLET, 

^ 

^ 

TROCHANTERS. 

9'f 

?^ 

RIGHT  OBLIQUE   INLET. 

4^ 

lO'V 

Spines, 

S> 

?? 

LEFT  OBLIQUE   INLET, 

4 

10 

Crests. 

8^ 

^1 

RIGHT  PeIvIc  wall 

T>'i 

^ 

External  Conjugate, 

^ 

\t% 

LEFT  Simc  WALL, 

,^^ 

9^ 

RIGHT  EXTERNAL  OBLIQUE, 

I?'!' 

m 

POSTERlSS'pELVIC  WALL. 

5.^ 

14 

LEFT  EXTERNAL  OBLIQUE, 

"^^^ 

^0 

SACRO-MCCySeaL  CURVE 

vS-;i 

/3'i 

Height  of  Symphysis, 

IV 

4- 

TRANSVERSE  OUTLET. 

^ 

^ 

DIAGONAL  CONJUGATE, 

21?- 

^'4 

''SutI!e°t';?oJ"g°e''al., 

rL^ 

s^ 

ANATOMICAL  CONJUGATE, 

rjr 

:? 

"oiIt?e°t';?aJrau,'' 

5| 

10 

Obstetric  Conjugate, 

1'^ 

4- 

CURVE  OF  SACRUM, 

N(REA(ED  1 

PUBIC  ANGLE 

(1 

O'l 

GROUP   XXIII.— DEFORMED   PELVIS.     FALSE   PROMONTORIES.     (HERGOTT.) 

Vide  Farabeuf,  31.,   Spondj'loschise,  Spondylolisth&se  and  Spondj'liz^me.     Bulletins  de  la  SoeieU  de  cJiirurgie,  1S85. 

04  mitural  size.) 


" 

" 

" 

rr-t 

CIRCUMFERENCE, 

?? 

5%\ 

TRANSVERSE  OF  INLET, 

5^i 

ml 

TROCHANTERS. 

II 'i 

?9 

RIGHT  OBLIQUE  INLET, 

\h\'!}A 

Spines, 

10!, 

?6 

LEFT  OBLIQUE  INLET 

^Id 

|3l 

Crests, 

II 

es 

RIGHT  PELVIC  WALL. 

Xy\ 

m 

External  Gorjugate, 

^'« 

in 

LEFT  ?lm  J  WALL, 

Vi^\\ 

RIGHT  EXTERNAL  OauQUE, 

d'4 

ao 

POST^RlSStELViC  WALL. 

5'4 

9 

LEFT  EXTERNAL  OBLIQUE. 

9 

25 

SACRO-COCC™  EAL  CURVE 

4? 

H'^ 

Height  of  Symphysis, 

\'-i 

4- 

TRANSVERSE  OUTLET, 

$ 

12', 

DIAGONAL  CONJUGATE. 

? 

m 

*S;TLE°T';?Scvi?E''AL.. 

\'i 

i\'i 

ANATOMICAL  CONJUGATE. 

A-% 

\<i 

*oJ"e°t™aJra'l°'' 

^ 

12  V 

Obstetric  Conjugate, 

5'< 

9 

CURVE  OF  SACRUM, 

fLATTENEol 

■C> 

PUBIC  ANGLE 

96"  \ 

GROUP    XXIV.— DEFORMED   PELVIS.     (GUICHARD,   OF  ,NANTES.) 

(3^  natural  size.) 


" 

TT 

T!? 

" 

CIRCUMFERENCE, 

If) 

m 

TRANSVERSE  OF   INLET, 

?1f 

9 

TROCHANTERS. 

n 

?-^ 

RIGHT  OBLIQUE  INLET 

4'? 

ir« 

Spines, 

9'-f 

2?^ 

LEFT  OBLIQUE  INLET, 

ys 

9 

Crests, 

9V 

?+ 

R,GHt"I'e°LvIc  WALL. 

s^ 

T 

External  Conjugate, 

fie 

Ifi 

LEFT  pIlvVJ  WALL, 

?'* 

8^- 

RIGHT  EXTERNAL  OBLIQUE, 

T'f 

If^'i 

POST?RlSS^PELVIO  WALL, 

$'s 

tJ. 

LEFT  EXTERNAL  OBLIQUE 

<yy 

}(•' 

SACRO-clcc™EAL  CURVE 

j'i 

<? 

Height  of  Symphysis, 

I'ff 

?^ 

TRANSVERSE  OUTLET. 

?'4 

6 

DIAGONAL  CONJUGATE 

n 

(^ 

^Sutl°j''<°oIc"'°"m: 

J^^ 

9'i 

ANATOMICAL  CONJUGATE, 

4-'s 

m 

''SjTLE°r';iAjRAU.'' 

Vc 

II 

Obstetric  Conjugate, 

4- 

10 

CURVE  OF  SACRUM, 

fUTTENEcl 

I-"* 

^ 

^ 

PUBIC  ANGLE 

56"   1 

AIDS  m  OBSTETRIC  TEACHING. 


PART    III. 


IV.  Miscellaneous  Models  and  Aids. 

A  FEW  metal  and  leather  models,  not  classifiable  under 
the  other  divisions  of  aids,  I  place  under  this  heading. 


KiG.  CO.— Metal  pelvia  and  tripod.    Useful  for  demonst.atmg  the  mechanism  of 
labor  and  obstetric  operations.    (From  a  photograpii.) 

1.  Aluminum  Cast  of  Sagittal  Mesial  Section  of  Bony 
Pelvis.* — The  first  that  we  have  to  ol!er  is  a  vertical 
mesial  section  of  the  female  bony  pelvis,  cast  in  alumi- 
num and  mounted  by  means  of  a  hand  screw  upon  a 
blackboard,  and  the  whole  set  in  a  tripod.  By  means 
of  a  narrow  nickel  band  the  right  half  of  the  pelvic  brim 
is  completed,  so  that  the  pelvic  inlet  shows  a  continuous 
line  without  a  break.  Eotation  on  a  transverse  axis  al- 
lows us,  by  means  of  the  hand  screw,  to  place  the  pelvis 
in  the  position  corresponding  to  the  dorsal  and  upright 
ones,  or  at  any  intermediate  angle  (see  Fig.  1). 

Below  the  aluminum  cast  I  have  outlined  perma- 

*  Made  by  the  Joljn  Reyudcra  Company,  New  York. 


nently  in  white  upon  the  board  a  vertical  mesial  section 
of  the  female  bony  pelvis,  in  the  position  corresponding 
to  the  dorsal  one,  and  with  the  diameters  and  axes  of  the 


Ftg.  61.— Leather  model  of  the  puerperal  uterus,  with  double  laceration  of  the 
cervix  and  opening  at  one  ^side  closed  by  tapes.  Useful  for  many  demon 
Btrations.    (From  a  photograph,)'.  See  Figs.  7.  and  8. 


bony  inlet  and  outlet  and  the  axis  of  the  partiirient 
outlet  added;  such  a  combined  blackboard  and  working 
model,  we  believe,  has  never  been  offered  before,  and 
without  using  it  one  can  scarcely  imagine  the  manifold 


FiQ.  02 — Leather  model  cf  pr.erperal  uterus,  showing  interim 
graph.) 


and  varied  uses  to  which  such  a  combination  may  be  put, 
as  the  invention  is  equally  useful  in  gynascological  as 
well  as  obstetrical  demonstrations. 


44 


AIDS  IN  OBBTETRIC  TEACHING. 


With  a  supply  of  puppets,  models  of  uteri,  and  col- 
ored chalk  at  our  disposal,  there  is  scarcely  an  obstetric 
or  gynajcological  condition  that  will  not  admit  of  a  con- 
cise ocular  demonstration. 


Fig.  03.— Reproduction  in  nibljrr  of  a  plaster  cast,  tnlcen  from  Nature,  of  tlie 
buttocks  and  vulva.  Useful  for  demonstrating  the  mechanism  and  manage- 
ment of  the  second  stage  of  labor.    (From  a  photograph.) 

The  metal  pelvis  (Fig.  70)  can,  with  advantage,  be 
used,  in  conjunction  with  the  present  sagittal  section 
of  the  pelvis,  in  many  ways  that  will  readily  suggest 
themselves  to  the  demonstrator.  If  desired,  the  same 
tripod  will  answer  for  both  contrivances. 


Fig.  G4.—E-xtemal  genital  organs.    Ni 
plaster  cast ;  from  a  photograph.) 


Copper-plated 


Fig.  1  shows  the  model  and  blackboard  mounted 
upon  the  tripod,  and  Figs.  2  to  6  indicate  a  few  of  the 
many  ocular  demonstrations  that  may  be  given  with  it. 

3.  Complete  Metal  Pelvis.* — The  complete  metal  pel- 


vis, mounted  upon  a  tripod,  has  already  been  described 
and  figured  in  a  paper  upon  obstetric  manikins  *  but  I 
take  the  opportunity  of  reproducing  it  here  (Fig.  60). 

Its  utility  is  attested  by  the  fact,  as  the  instrument 
maker  informs  us,  that  it  has  been  supplied  to  many 
of  the  medical  schools  of  this  country  and  Canada,  f 

3.  Leather  Model  of  Puerperal  Uterus-l — Such  a  sim- 
ple and  inexpensive  model  as  that  depicted  in  Fig.  61 


Fig.  (55.— Vagino-perineal  laceration  involving  the  right  lateral  sulcus.  Two 
internal,  or  vaginal,  and  two  external,  or  perineal,  sutures  in  place  ready  to 
be  tied.    (Copper-plated  plaster  cast ;  from  a  photograph.) 

can  readily  be  made  to  do  duty  in  various  kinds  of 
demonstration.  It  is  constructed  of  chamois  leather, 
lined  with  canvas,  and  may  be  opened  along  one  lateral 
half,  the  opening  being  closed  with  tapes  (Fig.   62). 

*  Edgar.  The  Manikin  in  the  teaching  of  Practical  Obstetrics.  New 
York  Medical  Journal,  December  27,  1S90. 

f  The  following  is  the  original  description :  For  demonstrating  the 
mechanism  of  labor  before  a  large  class — the  application  of  the  forceps, 
cranioclast,  cephalotribe,  and  other  obstetric  instruments ;  the  various 
methods  of  performing  version ;  the  different  methods  of  manual  e.x- 
traction,  whether  by  tlie  head,  shoulders,  breech,  or  lower  extremities — 
the  gmi-metal  pelvis,  covered  with  leather  and  mounted  upon  a  tripod, 
lias  proved  itself  exceedingly  useful  (Fig.  60). 

The  pelvis  is  practically  indestructible,  and  i.s  so  mounted  (Fig.  80) 
upon  the  upright  of  a  tripod  as  to  permit  of  rotation  in  an  entire  circle 
in  a  horizontal  plane,  which  allows  the  pelvic  outlet  or  inlet  to  be  directed 
to  any  point  desired. 

Besides  complete  rotation  in  the  plane  of  the  horizon,  partial  rotation 
upon  a  transverse  axis  is  also  easily  and  quickly  secured,  and  a  simple 
device  (Fig.  60),  in  the  shape  of  a  small  wheel  at  the  side,  enables  one 
to  fix  the  planes  of  the  pelvis  (represented  by  cardboard  if  need  be)  at 
any  desired  angle  with  the  horizon. 

If  desirable,  for  greater  convenience  and  accuracy,  a  simple  scale 
m.'iy  be  added  at  the  side,  which  will  enable  one  to  read  off  at  a  glance 
the  angle  produced.  A  movable  coccyx  permits  recession  during  the 
passage  of  the  foetus,  and  a  spring  throws  it  back  again  to  its  true  posi- 
tion. A  false  sacrum,  controlled  by  a  thumbscrew  passing  through  the 
true  sacrum,  enables  one  to  illustrate  contraction  of  the  pelvis  in  its 
antero-posterior  diameter,  or  to  fix  the  presenting  part  nf  the  puppet  or 
foc^tal  cadaver  in  any  desired  position. 

:);  Made  by  the  John  Reynders  Company,  New  Yorlv 


AIDS  m  0B8TETBI0  TEAOHINO. 


45 


The  cuff  of  the  partly  cut  away  vagina  is  represented 
by  a  piece  of  leather,  and  the  cervix  made  to  show  a  bi- 
lateral laceration,  extending  in  each  instance  as  far  as 
the  uterovaginal  junction. 

The  whole  roughly  resembles  the  puerperal  uterus 
at  the  beginning  of  the  puerperium. 

This  uterus  can  be  utilized  in  a  variety  of  ways:  alone 
to  show  manual  expression  of  the  placenta;  in  conjunc- 
tion with  the  metal  pelves  to  demonstrate  the  axis  of  the 
puerperal  uterus  and  puerperal  canal  and  Crede's  method 
of  placental  expression,  or  with  any  ordinary  manikin, 
to  illustrate  the  technics  of  various  puerperal  obstetric 
procedures.  With  this  simple  model,  together  with 
some  gauze,  volsella  forceps,  dressing  forceps,  needles, 
ligatures,  curettes,  and  a  speculum,  the  student  may  be 
made  familiar  with  that  manual  training  necessary  to 
ligate  the  bleeding  points  in  a  deeply  lacerated  cervix; 
to  pack  safely  the  puerperal  uterus  with  gauze  to  con- 
trol hjemorrhage  or  secure  drainage;  to  use  properly  the 
puerperal  curette,  so  as  to  reach  safely  the  fundus  with 
the  cautious  upstroke,  and  to  clear  it  of  debris  with  the 
more  forcible  clean  downward  sweep,  not  neglecting  to 
clear  the  eornua  at  the  same  time. 


id 6.  ^LL lures 


I^enSaUu'es 


i,  60.— VaffiuO'Perineal  laceration  involving  both  lateral  sulci.  Three  inter 
nal,  or  vaginal,  and  two  external,  or  perineal,  Butures  in  place  ready  to  be 
tied.    (Copper-plated  plaster  cast ;  from  a  photograph.) 


In  order  that  the  student  shall  acquire  this  manual 
training,  it  has  been  our  custom  to  place  the  proper  in- 
struments in  his  hands  and  require  him  to  carry  out  the 


procedures  above  referred  to.    His  handling  of  the  cu- 
rette is  then  criticised;  the  model  is  opened  and  the 


ur&J 


Per.  futures 


Fig.  67. — Vagino-perineal  laceration  in' 
and  perinjenm  to  the  sphincter  an 
external,  or  perineal,  sittures  in  pla 
ter  cast ;  from  a  photograph.) 


)lviDg  right  po.«tero-lateral  vaginal  wall 

Four  internal,  or  vaginal,  and  three 

i  ready  to  be  tied.    (Copper-plated  plas- 


manner  of  the  gauze  packing  inspected,  and  if  he  has 
failed  to  reach  the  fundus  with  the  gauze,  his  fault  ex- 
plained to  him.  So  also  the  ligature  in  the  cervical 
laceration  is  looked  to,  and  the  student's  errors  in  technic 
corrected. 

I  have  intended  in  this  model  to  supply  to  the  stu- 
dent the  means  and  the  opportunity  to  acquire  that  kind 
of  manual  training  in  certain  obstetric  procedures  which 
may  never  occur  to  him  until  he  is  in  active  practice, 
and,  moreover,  the  manual  training  that  will  save  the 
physician's  first  eases  of  confinement  much  that  would 
otherwise  be  but  crude  and  experimental,  if  not  actually 
dangerous,  treatment. 

Fig.  7  represents  the  use  of  the  leather  uterus  in 
a  manikin.  The  uterus,  drawn  down  into  the  vulva  by 
means  of  two  volsella  forceps,  and  is  held  by  an  assistant; 
with  blunt-pointed  dressing  forceps  the  student  proceeds 
to  pack  the  uterus  with  gauze  from  a  glass  receptacle,  the 
fingers  and  palm  of  the  left  hand  being  used  as  a  trough 
to  guide  the  gauze  directly  from  the  glass  tube  into  the 
uterine  cavity,  thus  avoiding  all  contact  with  adjacent 
unclean  tissues. 

Fis.   8   illustrates  the   uterus  drawn   down   in  the 


46 


AIDS  m  OBSTETRIC  TE AGEING. 


same  manner,  and  the  student  with,  needle  and  holder 
applying  a  ligature  to  a  bleeding  lacerated  cervix. 


—Laceration  of  right  postero-iateral  vaginal  wall,  perinseum,  and  ante 
rior  rectal  wall  througli  the  sphincter.  Four  rectal  sutures  and  one  silver 
wire  suture,  the  latter  tranefixins  torn  ends  of  sphincter  muscle  and 
encircling  apes  of  rectal  laceration,  in  place  and  ready  to  be  tied.  (Copper- 
plated  plaster  cast ;  from  a  photograph.) 


Deep  ^  i  Iver  /^uZure' 


FiQ.  69.— Rectal  sutiu-es  of  Fig.  08  tied  and  cut  short  in  rectum.  Silver-wire 
sphincter  suture  and  four  vaginal  sutures  in  place  and  ready  to  be  tied. 
(Copper-plated  plaster  cast ;  from  a  photograph.) 

4.  Ritiier   Perinasum   and    Vulva. — In   Fig.    63   is 
shown  a  rubber  pelvic  floor  taken  from  Nature.    A  plas- 


ter cast  in  this  model  was  first  taken  from  the  living  sub- 
ject, this  in  turn  cast  in  iron,  and  from  this  latter  rubber 


Pig.  70.— Vaginal 

to  be  tied.    (Copper-plated  plaster  cast ;  from  a  photograph.) 

models  were  made.    It  supplies  the  place  of  the  ordinary 
manikin  for  class-room,  chnic,  or  ward  demonstration. 


A  tLulsted 


Pig.  71.— Perineal  sutures  of  Fig.  70  tied.  Ends  of  deep  silver  suture  transfix- 
ing sphincter  muscle  twisted  Ends  of  rectal  sutures  hidden  by  closed  anus. 
Vaginal  sutures  seen  to  the  right.  (Copper-plated  plaster  cast ;  from  a  pho. 
tograph.) 

and  has  the  additional  advantage  of  being  readily  por- 
table and  capable  of  being  kept  perfectly  clean. 


AIDS  m  OBSTETRIC  TEAGEINO. 


47 


V.  JUledro-plated  Plaster  Models. 

Experience  has  taught  us  that  the  papier-mache 
method  is  not  applicable  for  very  small  objects  where 
minuteness  of  detail  is  required.  I  refer  more  particu- 
larly to  the  non-pregnant  uterus,  the  pregnant  uterus  in 
the  early  months,  conditions  of  the  cervix,  lacerations  of 
the  vagina  and  pelvic  floor.  We  have  therefore  hit 
upon  a  method  of  illustration  which  has  given  the  great- 
est satisfaction,  and  secures  for  us  a  model  which  is 
comparatively  light,  practically  indestructible,  and 
leaves  nothing  to  be  desired  in  accuracy  of  detail,  as  the 
original  and  permanent  model  is  a  plaster  cast  taken 
from  Nature. 

If,  for  example,  a  reproduction  of  the  multiparous 
uterus  is  desired,  as  soon  as  possible  after  its  removal 
from  the  cadaver  a  model  in  plaster  of  Paris  is  taken  of 
it.  From  this  model,  subsequently,  any  number  of  casts 
or  models  may  be  reproduced.  These  are  allowed  to 
dry  thoroughly,  and  are  then  sent  to  an  electrotyper, 
who,  at  a  trifling  expense,  throws  a  layer  of  copper  over 
the  plaster  cast,  and  afterward  the  model  can  be  col- 
ored in  any  desired  manner.  In  this  way  were  obtained 
the  smaller  uteri  represented  in  Figs.  10  and  11,  and  the 
several  degrees  and  varieties  of  perineal  lacerations  arti- 
ficially produced  upon  the  cadaver  and  represented  in 
Figs.  64  to  71. 

We  need  not  confine  ourselves  to  plaster  as  regards 
copper-plating,  as  bone,  composition,  and  clay  may  be 
subjected  to  the  same  process.  All  the  models  of  pelvic 
deformity  (groups  1  to  24)  were  treated  in  the  same  way 
for  the  sake  of  strength  and  durability. 

1.  Lacerations  of  Vagina,  Perinceum,  and  Anterior 
Rectal  Wall. — My  aim  in  this  direction  has  been  to  pro- 
duce a  series  of  models  that  shall  illustrate  the  ordinary 
degrees  of  vaginal,  perineal,  and  rectal  lacerations  pro- 
duced during  childbirth.  To  this  end  at  first  I  confined 
myself  to  plaster  casts  taken  from  the  living  subject 
at  the  completion  of  the  puerperium.  This  proved 
unsatisfactory,  however,  because  of  contraction  and 
distortion  of  the  parts  in  question,  so  that  the  series 
herein  offered  represents  plaster  casts  of  artificially  pro- 
duced lacerations  with  the  knife  upon  the  cadaver.  The 
positive  mold  being  taken  in  plaster  of  the  injury  pro- 
duced, a  second  positive  in  glue  was  taken  from  this, 
and  then  negative  plaster  casts  taken  from  the  glue  posi- 
tive and  copper-plated.  These  latter  are  then  completed 
by  the  insertion  of  sutures  by  means  of  an  ordinary  drill. 

This  series  includes  (1)  a  cast  of  the  nulliparous  geni- 
tals, showing  the  fourchette,  from  which  the  subsequent 
casts,  with  injuries,  were  secured  (Fig.  64);  (2)  a  vagino- 
perineal laceration  involving  the  right  lateral  vaginal  sul- 
cus, -with  sutures  for  repair  in  position  (Fig.  65);  (3)  va- 
gino-perineal  laceration,  involving  both  lateral  sulci,  with 
sutures  for  repair  in  position  (Fig.  66);  (4)  vagino-peri- 
neal  laceration,  involving  right  postero-lateral  vaginal 
wall  and  perinasum  to  the  sphincter  ani,  with  sutures 
for  repair  in  position  (Fig.  67);  (5)  laceration  of  right 


postero-lateral  vaginal  wall,  perinaeum,  and  anterior  rec- 
tal wall  through  the  sphincter,  sutures  for  repair  of  rec- 
tal wall,  and  suture,  including  sphincter,  in  place  (Fig. 
68);  (6)  rectal  sutures  tied  and  cut  short,  wire. sphinc- 
ter suture  ready  to  be  tied,  vaginal  sutures  in  position 
(Fig.  69);  (7)  vaginal  sutures  tied,  external  perineal 
sutures  in  position  (Fig.  70);  (8)  external  perineal  su- 
tures tied  (Fig.  71). 

2.  Pelvic  Deformity. — The  subject  of  pelvic  deform- 
ity has  always  been  one  of  the  dryest  and  most  uninter- 
esting to  the  student,  and  one  of  the  most  difficult  for 
the  instructor  to  teach.  Little  more  than  a  temporary 
impression  is  made  by  diagrams,  verbal  and  printed  de- 
scriptions, and  by  perhaps  an  occasional  cUnical  demon- 
stration of  some  form  of  pelvic  deformity,  so  that  at 
graduation,  and  even  later  in  the  pupil's  professional  ca- 
reer, the  various  deformities,  whether  they  be  congeni- 
tal or  produced  by  rhachitis,  osteomalacia,  ankylosis,  or 
adventitious  causes,  too  often  escape  notice  until  the  pa- 
tient is  perhaps  well  in  the  first  stage  of  labor.  We  have 
always  believed  that  the  best,  if  not  the  only  satisfactory 
method  for  the  pupil  to  acquire  an  intelligent  apprecia- 
tion of  this  subject  is  to  place  in  his  hands  the  various 
deformed  pelves,  and  with  the  normal  type  in  view  be- 
fore him  require  the  student  to  point  out  the  departures 
from  the  normal  in  the  deformed  pelvis.  This  can  readi- 
ly be  made  a  stepping-stone  to  the  causes  of  such  abnor- 
mities, the  diagnosis  and  prognosis  of  the  same,  and 
the  treatment  appropriate  to  meeting  the  condition  in 
pregnancy  or  labor.  Commencing  with  the  moderate 
deformities,  the  more  marked  and  rarer  conditions  can 
then  be  gradually  approached.  So  in  the  obstetric  cliniCj 
hospital  ward,  or  the  dispensary,  examination  of  preg- 
nancy, varieties  of  pelvic  deformity,  with  their  prognosis 
and  treatment,  can  be  brought  home  to  pupils  in  a  man- 
ner never  before  thought  possible,  if  at  our  command 
we  possess  a  series  of  deformed  pelves  from  which  one 
resembling,  if  not  exactly  corresponding  to,  the  abnor- 
mity can  be  chosen.  Heretofore  this  want  we  have 
been  unable  to  meet  in  the  recitation  room  or  hospital. 
The  limited  number  of  specimens  of  pelvic  deformity  to 
be  found  in  any  single  college  or  hospital  museum  are 
practically  non-accessible  to  the  student  or  practitioner, 
and  surely  are  too  valuable  and  fragile  to  allow  of  re- 
peated handling  and  study. 

Eecently  Tramond,*  of  Paris,  has  completed  a  series 
of  twenty-two  deformed  pelves. 

This  collection  consists  of  twenty-two  plaster  models, 
with  artificial  ligaments  added,  being  correct  repro- 
ductions of  the  originals  now  in  possession  of  private  in- 
dividuals or  of  the  museums  of  Paris. 

The  series  offers  examples  of  the  principal  malforma- 
tions, and  there  are  in  addition  two  pelves  of  normal  con- 
formation— namely,  the  male  and  female  types, 
twenty-four  models  in  all. 

*  Maison  Vasseur,  9  rue  de  I'Ecole  de  M6deoine. 


48 


AIDS  IN  OBSTETRIC  TEA  CHIN 0. 


In  a  number  of  the  titles  of  the  pelves  herein  given  is 
included  the  owner  of  the  original  or  the  museum  where 
found.  Such  a  collection  has  been  of  great  help  to  us  for 
several  years  past,  and  had  we  not  hit  upon  some  means  to 
render  the  models  more  durable,  would  not  at  the  pres- 
ent writing  be  presentable.  To  meet  the  wear  and 
tear  of  repeated  handling  and  demonstration,  we 
have  had  these  pelves  sent  to  an  electrotyper  and 
a  thin  film  of  copper  thrown  over  them.  This  cop- 
per-plating does  not,  to  any  extent,  change  the  pro- 
portions of  the  original  pelves,  but  renders  them  prac- 
tically indestructible,  and  a  coat  of  paint  will  easily 
restore  the  original  natural  appearance.  Very  slight  ad- 
ditional weight  is  added,  and  the  plated  model  can  be 
cleansed  and  thus  rendered  free  from  suspicion  for  clini- 
cal or  bedside  demonstration. 

Believing  this  series  of  deformed  pelves  to  be  of  value 
not  only  to  the  teacher  of  obstetrics  but  to  the  general 
practitioner  and  surgeon  as  well,  I  have  made  it  a  basis 
of  study,  making  complete  measurements  of  each  pelvis, 
offering  a  photograph  of  the  pelvic  inlet  and  outlet  of 
each,  an  outline  of  a  lead  cast  to  show  the  vertical  mesial 
section,  with  the  lumbo-sacro-coccygeal  curve,  the  incli- 
nation and  shape  of  the  symphysis,  and  the  relations  of 
the  anatomical,  obstetric,  and  diagonal  diameters  of  the 
pelvic  inlet,  and  also  the  sacro-  and  coccygo-pubic  diame- 
ters of  the  outlet. 

Of  the  three  conjugates  appearing  in  each  vertical 
mesial  section,  I  have  emphasized  the  obstetric  by  draw- 
ing here  a  heavier  line,  and  it  is  well  to  state  at  this  point 
that  we  define  the  obstetric  conjugate  as  the  available 
antero-posterior  diameter  of  the  pelvic  inlet. 


DISCUSSION    OF   THE   PAPER, 

"AIDS   IN   OBSTETRIC   TEACHING,"   BY   THE 

AMERICAN  GYNAECOLOGICAL   SOCIETY, 

New  Yorh,  May  26,  1896. 

Dr.  A.  H.  BuoKMASTEE,  of  Charlottesville,  Va. — 
I  wish  to  express  my  admiration  of  these  beautiful  casts, 
and  also  to  call  attention  to  a  practical  method  of  re- 
producing casts  from  the  living  as  well  as  the  dead  sub- 
ject. It  is  by  the  use  of  iiarafrin,  mid  T  think  ilint  il 
has  some  advantages  over  Ihr  iin'lhnd  whirli  llic  doclor 
described.  The  method  is  iml  oi-igmal  willi  myscir.  Imt 
was  used  in  1880  or  1881  by  Dr.  Tetamore,  of  Long 
Island  College,  for  maldng  some  beautiful  casts, of  the 
brain.  It  is  a  very  simple  one.  The  paraffin  can  be 
applied  with  a  fine  eamel's-hair  brush,  and  when  care- 
fully used  it  causes  the  patient  but  slight  pain.  When 
a  sufficient  amount  of  paraffin  has  been  used  it  is  re- 
moved, and  at  a  later  period  is  backed  with  plaster. 
Into  this  paraffin  cast  the  plaster  is  run,  and  you  have 
a  perfect  reproduction  of  the  condition.  The  decussa- 
tion of  the  pyramids  can  be  perfectly  shown  by  this 
method.  I  made  some  casts  four  or  five  years  ago  just 
before  operation,  and  then  made  casts  at  a  later  period 
in  order  to  show  the  results  of  restoration  of  the  pelvic 


floor.  I  think  that  this  method  has  some  advantages 
over  that  described  in  the  paper.  I  would  like  to  urge 
its  adoption  generally. 

Dr.  EoBEET  A.  Murray,  of  New  York. — We  have 
all  been  intensely  interested  by  Dr.  Edgar's  casts  of  the 
pelvis,  and  also  those  of  the  child  which  is  to  go  tlirough 
the  pelvis.  When  I  was  connected  with  the  Universitj' 
Jledical  College,  and  gave  cases  to  the  third-course  stu- 
dents to  deliver,  it  seemed  to  me  that  the  important 
points  were  two:  1,  the  size  of  the  pelvis;  2,  the  size  of 
tlie  child.  Now,  if  you  will  notice  the  statistics  in  Ger- 
many, you  will  find  that  the  average  weight  of  the  child 
is  about  six  pounds  and  a  half.  In  New  York,  with  the 
more  perfect  nutrition  of  the  child,  due  to  the  better 
nutrition  of  the  mother,  and  in  all  our  States,  the 
child  is  usually  larger  than  in  Germany,  Italy,  and 
France.  That  is,  it  is  ordinarily  not  six  pounds, 
or  six  and  a  half,  but  seven  pounds  and  a  half. 
Now,  we  do  not  have  in  New  York,  nor  in  Chi- 
cago, nor  in  any  of  the  cities  of  the  Union,  the  deformed 
pelvis  that  we  ordinarily  see  in  the  Italians,  in  the  Ger- 
mans, and  in  the  French,  who  come  here.  Why?  Be- 
cause our  people  have  had  more  perfect  nutrition.  They 
have  not  had  to  work  when  the  pelvis  was  imperfectly 
formed.  They  have  had  sufficient  nutrition,  and  nutri- 
tion of  a  land  to  develop  the  pelvis.  So  that  we  have 
not  the  pelvis  which  is  deformed  absolutely,  but  one 
which  is  small  relatively  to  the  child  which  is  to  pass 
tlirough  it.  It  becomes  a  question  of  mechanics,  wheth- 
er the  child  can  pass  through  the  pelvis.  We  have  very 
seldom  a  cordiform  pelvis,  seldom  a  Roberts's  pelvis. 
We  do  not  have  a  pelvis  in  which  the  coccyx  tump  up 
at  the  outlet,  with  marked  contraction  at  the  ou. 
and  in  which  laceration  of  the  periuEeum  through  the 
sphincter  is  likely  to  take  place. 

If,  then,  the  student  of  midwifery  would  have  ab- 
solute knowledge  of  his  case,  he  must  have  knowledge 
of  the  child  which  is  to  pass  through  the  pelvis,  as  well 
as  of  the  characteristics  of  that  pelvis.  Now,  how  are 
we  to  determine  that  relationship  between  pelvis  and 
foetus?  The  student  may  study  these  casts.  He  may 
learn  to  do  version.  He  may  learn  how  to  apply  forceps. 
He  may  learn  the  different  characteristics  of  the  pelvis, 
and  I  must  congratulate  Dr.  Edgar  on  the  very  happy 
way  in  which  he  makes  those  different  deformities  of 
ihe  pelvis  evident  to  the  student.  Ordinarily  the  stu- 
dent only  knows  that  the  male  pelvis  differs  from  the 
female.  But  here  we  have  it  shown  absolutely,  so  that 
tlic  student  knows  about  the  male  and  female  pelvis, 
about  the  pelvis  which  is  contracted  at  the  inferior  strait, 
the  spondylolisthetic  pelvis,  etc.  And  until  there  is  a 
diameter  reduced  belowr  two  inches  and  three  quarters 
he  (Iocs  iKit  almudon  the  hope  of  delivering  tlirough 
I  he  iialiir.il  (  hiiiiiu'].  He  also  learns  to  determine  what 
is  llic  si/.c  o(  tlic  child's  head  as  he  feels  it  above  the 
pubes.  He  then  knows  wdiether  he  has  to  do  a  sym- 
physeotomy, a  Ca!sarean  section,  or,  if  he  introduces 
forceps  and  extracts  the  child,  whether  he  will  be  likely 
to  save  it.  He  knows  all  that,  and  that  is  why  I  con- 
gratulate my  friend  Dr.  Edgar  for  demonstrating  these 
things  to  students  before  they  have  had  the  opportunity 
to  examine  and  estimate  the  size  of  the  pelvis  during 
the  state  of  pregnancy. 

Dr.  A.  P.  A.  King,  of  Washington,  D.  C— In  the 
evolution  and  development  of  any  science,  and  in  the 
teaching  of  any  art.  new  necessities  are  constantly  aris- 
ing. Now  the  necessity  has  arisen  in  the  teaching  of  ob- 
stetrics, in  the  absence  of  clinical  teaching,  to  fumi.sh 


AIDS  IN  OBSTETRIC   TEAOEINO. 


49 


a  substitute.  It  is  very  fortunate  tliat  when  these  ne- 
cessities arise  tliere  also  occasionally  appears  a  man  oi; 
originality  and  intelligence  to  grapple  with  the  new 
necessity  and  to  provide  the  means  of  overcoming  it. 
Dr.  Edgar,  with  his  intelligence  and  originality,  has 
arisen  in  this  country  to  furnish  a  substitute  for  the  ne- 
cessity of  clinical  teaching,  and  he  has  done  it,  or  has 
begun  it  at  least,  in  a  most  admirable  manner.  I  think 
that  we  are  all  extremely  grateful  to  him  for  the  ad- 
vance he  has  made  in  this  substitute  for  clinical  teach- 
ing. 

Now,  I  have  only  one  or  two  ideas  to  suggest.  One 
is  that  in  the  absence  of  bedside  teaching,  which  after 
all  is  the  only  real  method  of  teaching  obstetrics,  this 
substitution  of  models  is  the  best  that  we  can  do.  It 
is  of  the  greatest  importance  that  the  student's  fingers 
should  be  educated,  and,  if  Dr.  Edgar  would  exercise 
his  ingenuity,  I  think  that  he  might  devise  a  model 
which  every  student  should  buy — just  as  he  now  buys 
a  pelvis  or  a  skeleton  to  learn  anatomy — a  device  con- 
taining a  model  of  the  foetal  head  susceptible  of  being 
moved  around  in  every  direction,  having  the  exact  ana- 
tomical construction  of  the  foetal  head.  This  the  stu- 
dent may  carry  with  him  to  his  room,  and  educate 
his  fingers,  just  as  he  would  educate  his  muscles 
with  dumb-bells  every  morning,  so  that  he  will 
become  absolutely  familiar  with  the  sutures,  fonta- 
nelles,  and  general  anatomical  structures  of  the  fcetal 
head. 

Another  idea  which  would  suggest  itself  has  occurred 
to  me  for  many  years.  I  do  not  know  whether  it  is  prac- 
ti'-al  or  not,  but  in  a  large  lecture  room,  like  those  in 
_  ,me  of  the  schools  here  in  New  York,  where  seven  or 
eight  hundred  matriculants  are  collected  in  a  large  am- 
phitheatre, how  little  they  can  see  in  a  case  of  labor, 
or  by  a  small  model,  like  Dr.  Edgar's!  If  Dr.  Edgar 
would  exercise  his  originality  and  ingenuity  he  might 
devise  a  very  large  pelvis,  eight  or  ten  times  as  big  as 
this  one,  and  then  hire  a  newsboy,  eight  or  ten  years 
old,  anoint  him  with  vaseline,  have  the  pelvis  elastic  so 
as  to  avoid  the  danger  of  strangling  him,  and  demon- 
strate before  these  enormous  classes  the  mechanism  of 
labor. 

There  is  one  other  suggestion.  It  is  a  lamentable 
fact  that  while  most  universities  are  so  richly  endowed 
in  most  of  their  departments,  in  nearly  all  these  insti- 
tutions the  medical  school  is  the  very  last  department 
to  receive  endowments.  Now,  it  is  a  curious  thing  that 
while  hundreds  of  thousands  of  dollars  are  given  many 
universities  to  build  laboratories,  gymnasiums,  dormi- 
tories, and  nearly  everything  else,  it  is  very  seldom  that 
we  get  a  donation  for  a  medical  institution.  In  New 
York  there  are  exceptions,  as  the  Sloane  Maternity, 
and  some  others,  but  most  universities  have  no  provision 
of  this  sort.  I  wish  that  this  society  coixld  make  itself 
heard  through  this  country  in  impressing  the  necessity 
for  raising  money  to  estalDlish  maternity  hospitals  for 
teaching  obstetrics.  Until  we  accomplish  this  of  course 
we  can  never  compete  with  the  great  schools  of  Europe 
■ — in  Vienna,  in  Dublin,  and  other  cities — where  actual 
clinical  material  is  provided,  and  which  is  really  the  only 
proper  method  of  teaching  next  to  the  use  of  Dr.  Ed- 
gar's admirable  models  and  manikins. 

Dr.  Edward  Reynolds,  of  Boston. — I  have  known 
for  some  years  that  Dr.  Edgar  was  doing  pioneer  work 
for  all  of  us  in  this  direction,  and  I  have  iDeen  extremely 
interested  to  see  his  collection  of  models.  There  is  not 
much  that  one  can  say  in  the  discussion  of  such  a  paper, 


but  I  sincerely  hope  that  Dr.  Edgar  is  going  to  elaborate 
his  system  of  models  in  the  direction  of  providing  stu- 
dents with  more  and  more  exact  exhibitions  of  the 
mechanism  of  labor. 

I  believe  that  in  obstetrics  it  is  peculiarly  important 
to  graduate  students  with  a  clear  and  definite,  even 
though  limited,  set  of  ideas;  that  in  the  emergencies 
which  test  the  results  of  our  obstetric  teacliing  it  is  far 
better  for  them  to  meet  their  cases  with  a  concise  and 
definite  knowledge  of  one  method  of  dealing  with  the 
emergency,  rather  than  to  be  taught  the  pros  and  cons 
and  wherefores  without  end.  I  believe  that  in  order  to 
fit  men  to  deal  with  abnormal  labor  promptly  and  effi- 
ciently, a  large  portion  of  the  time  devoted  to  obstetrics 
must  be  given  to  careful  drill  in  the  mechanism  which 
underlies  the  whole  subject,  and  without  which  there 
is  no  possibility  of  its  proper  comprehension.  Dr.  Edgar 
is  showing  us  the  way  to  teach  students  the  mechanism 
of  labor,  for  I  believe  with  him  most  heartily  that  there 
is  no  possibility  of  teaching  subjects  of  three  dimensions 
clearly  by  the  use  of  plates  of  two  dimensions,  or  by 
mere  words.  We  must  have  models  in  three  dimensions, 
and  I  for  one  look  forward  to  Dr.  Edgar's  future  work  as 
likely  to  furnish  us  all  with  an  easy  means  of  good 
teaching,  which  we  have  not  to-day. 

Dr.  Edwahd  p.  Davis,  of  Philadelphia. — Dr.  Ed- 
gar seems  to  me  to  have  represented  better  than  has 
been  done  abroad  some  work  which  has  been  done  by 
others,  and  then  to  have  added  several  distinct  and 
purely  original  and  most  meritorious  things.  The 
leather  uterus  reminds  me  of  the  rubber  uterus  of 
Winckel,  by  which  the  palpation  of  the  foetal  cadaver 
can  be  in  a  measure  learned.  With  wax  casts  we  are 
more  or  less  familiar,  but  to  my  mind  the  best  things 
that  Dr.  Edgar  has  given  us  are  this  tripod  with  its 
aluminum  half-pelvis,  and  also  his  method  of  plaster 
illustration  of  lacerations  of  the  parturient  tract. 

If  I  mistake  not.  Dr.  Edgar  has  not  done  himself 
full  justice  in  the  idea  of  the  tripod,  as  he  uses,  I  think, 
a  pelvis  of  metal  and  a  tripod  in  which  he  places  the 
fcEtus  in  the  position  of  normal  labor  when  illustrating 
his  lectures,  so  that  this  is  but  a  part  of  his  work  in  that 
line. 

These  illustrated  lacerations  are  certainly  better 
than  any  which  have  before  come  under  my  observation. 
They  represent  in  a  clean  and  exact  way  an  actual  re- 
production of  the  lesion  and  the  method  of  treatment. 

Referring  to  what  has  been  said  of  the  value  of  edu- 
cation in  three  dimensions,  there  is  certainly  no  better 
way  of  teaching  the  mechanism  of  labor  than  by  giving 
to  each  student  a  pelvis  and  head  with  normal  dimen- 
sions, and  educating  his  finger  to  recognize  the  relative 
proportion  of  the  one  to  the  other.  When  thrown  upon 
his  own  resources  he  may  be  without  the  means  of  ac- 
curate measuremeiit,  but  the  finger  which  recognizes  the 
fact  that  the  head  does  not  engage  in  the  ^  dlvis  is  the 
safe  finger  for  obstetric  practice,  and  that  can  be  taught 
by  placing  the  normal  head  in  a  model  of  a  pelvis  suffi- 
ciently deformed  to  prevent  engagement  of  the  head. 
That  is  one  thing  which  the  student  must  know,  or  he 
will  apply  forceps  to  the  disaster  of  the  mother  and 
child. 

There  remains  a  way  for  further  advancement  in 
illustrating  obstetrics  in  a  most  interesting  direction — 
namely,  that  of  the  Roentgen  rays  for  photographing, 
or  skiagraphing,  the  living  pelvis  and  uterus.  The  time 
of  exposure  now  necessary  has  been  reduced  to  about 
one  minute,  but  the  one  element  which  has  baffled  us 


50 


AIDS  IN  OBSTETRIC  TEACHINO. 


in  obstetrics  is  the  fact  tliat  the  fcetus  is  in  almost  con- 
stant motion,  and  it  has  so  far  been  impossible  to  clearly 
skiagraph  the  living  foetus.  When  the  time  of  exposure 
shall  be  so  reduced  that  the  fcetal  movements  shall  offer 
no  serious  obstacle  we  may  hope  that  Dr.  Edgar  will 
supplement  his  admirable  work  with  skiagraphy. 

Dr.  ]<]dgar. — There  is  very  httle  left  to  say.  With 
regard  to  Dr.  Buckmaster's  remarks,  I  would  imagine 
that  paraffin  would  do  very  well,  but  in  my  hands  it  has 
not  given  the  same  success  as  plaster.  Plaster  has  cer- 
tainly taken  in  all  the  depressions  and  elevations  in  a 
satisfactory  manner,  as  is  shown  by  the  casts  of  the 
vaginal  and  perineal  lacerations. 

In  reply  to  Dr.  Murray,  I  do  not  know  whether 
he  misunderstood  the  paper,  but  I  did  not  at  all  mean  to 
imply  tliat  tlie  models  and  methods  a-ef erred  to  were  to 
take  the  place  of  clinical  instruction.  They  were  only 
to  act  as  adjuncts  and  aids  to  such  instruction. 

I  want  to  thank  Dr.  King  for  his  kind  words,  and 
T  would  like  to  repeat  to  him  that  all  this  paraphernalia 
is  meant  to  be  used  in  maternity  hospitals  as  well  as  in 
the  lecture  room.  I  might  say  that  there  are  two  peri- 
ods in  the  student's  career  when  these  adjuncts  come 
into  play:  during  the  second  year,  when  he  is  prepar- 
ing for  obstetric  work,  and  later,  when  he  is  in  the  ma- 
ternity service  and  is  seeing  cases  of  confinement,  in 
order  to  illustrate  more  graphically  parts  out  of  sight 
In  reply  to  Dr.  King's  suggestion,  I  would  say  that  I 
have  such  a  pelvis,  which  is  three  times  the  size  of  this 


one  (normal  pelvis),  but  I  could  not  get  it  into  the  cab, 
consequently  it  remains  at  the  foundiy.  I  have  not  yet 
secured  the  newsboy,  but  Mr.  Reynders  is  preparing  a 
piippet  which  is  exactly  three  times  the  size  of  one  of 
these  which  you  see — i.  e.,  three  times  the  normal  size. 

Again,  in  connection  with  Dr.  King's  remarks,  I 
would  like  to  say  that  we  do  have  an  abundance  of  clini- 
cal teaching  here  in  New  York;  that  the  students  from 
all  the  principal  medical  schools  are  required  now  to 
take  a  two  weeks'  course  and  to  confine  a  number  of 
patients.  They  take  it  in  the  most  practical  way  im- 
aginable; that  is,  they  actually  confine  the  women. 
They  live  in  the  hospital,  and  during  the  intervals  be- 
tween the  confinements  they  attend  the  operations  or 
clinics  going  on  in  the  institution. 

I  would  like  to  have  referred  further  to  the  mechan- 
ism of  labor,  as  Dr.  Eeynolds  has  suggested,  but  the 
time  was  so  limited  that  I  was  unable  to  do  so'.  The 
primary  idea  was  to  show  the  posture  of  the  child,  inter- 
nal rotation,  extension,  and  flexion:  that  is,  to  give  an 
ocular  demonstration  of  the  mechanism  of  labor.  Some 
of  the  remarks  I  was  compelled  to  leave  out  (they  will 
apjiear  in  the  ]:iublished  paper)  which  apply  more  par- 
ticularly to  the  mechanism  of  labor. 

I  wish  to  thank  Dr.  Davis  for  his  kind  words.  I  did 
not  refer  to  the  full  model  of  the  pelvis,  which  he  spoke 
of,  because  it  had  already  been  presented  to  the  New 
York  Obstetrical  Society.  The  tripod  is  interchange- 
able. 


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